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Purpose: In previous studies the degree of embolization detected by transoesophageal echocardiography (TEE) during cemented total hip arthroplasty (THA) did not correlate with changes in haemodynamic variables nor did it result in persistent ventilation-perfusion mismatching. The aim of this study was to record evidence of embolism and to relate the findings to demographic data and the subsequent clinical course of the patients during THA., Method: Forty-eight patients scheduled to undergo elective cemented THA during general anaesthesia were monitored. A TEE probe was inserted with special attention to the right atrium (RA), the right ventricle (RV) Haemodynamic (heart rate, arterial blood pressure, central venous pressure) and blood-gas variables were measured repeatedly during the operative procedure (after induction, placement of the acetabular component, placement of the femoral component, relocation of the hip joint). Grading of venous embolism at these times was based on the size of particles detected by TEE (three-minutes video segments of each periods) and correlated with demographic, haemodynamic and blood-gas data., Results: The TEE monitoring revealed showers of echogenic material traversing the RA and RV in all but one patients during reaming and cementing of the acetabular and femoral components, and during relocation of the hip joint. No correlation was observed between frequency or size of embolic particles and demographic or blood-gas and haemodynamic variables studied at the same times., Conclusion: This study failed to show any clinical impact of TEE detected emboli during cemented THA.

This study aimed to determine the incidence and diagnostic value of fat-laden alveolar macrophages obtained by bronchoalveolar lavage (BAL). In 128 patients, including 66 patients admitted for multiple trauma, 158 BAL were carried out. However, 41 BAL from 32 patients were excluded because of poor quality of samples (not enough macrophages, too many ciliated cells, or haemorrhage). All the patients were intubated and mechanically ventilated, having pulmonary infiltrates on the chest film. BAL samples were examined after staining with oil-red-O. They were considered to be positive when more than 5% of alveolar macrophages contained fat droplets. Among them 14 out of 47 patients (30%) without multiple trauma were positive; 7/14 had never been given any intravenous lipid infusion, and 5/14 had aspiration pneumonia (as opposed to 3/32 patients with negative BAL). Further 27 patients out of the 49 (55%) with multiple trauma were positive. Among them 10/49 had clinical evidence of fat embolism, however, only 7/10 had positive samples. All these last ten patients had been given intravenous lipid infusions. The rate of positive alveolar macrophages was correlated neither with the plasma triglyceride concentration, nor the Fracture Index Score, nor the delay between the end of the lipid infusion and the BAL. There was no significant difference in PaO2/FIO2 ratio between the patients with positive and negative BAL. Positive BAL was significantly associated with lipid infusions. The data therefore suggest that the presence of fat-laden alveolar macrophages are associated with various pathological pulmonary conditions, particularly aspiration pneumonia and lipid infusions.(ABSTRACT TRUNCATED AT 250 WORDS)

Regional anesthesia represents a selective approach in shoulder surgery. The following technics can be used: brachial plexus block, cervical epidural and intra-articular anesthesia. The advantages of each technique are discussed.

Fat embolism syndrome (FES) is a rare but serious complication occurring after long bone fractures. Presence of fat droplets in cells obtained by bronchoalveolar lavage has been proposed as a specific tool for FES diagnosis in trauma patients. We evaluated this technique over a 15-month period in 85 patients. Twenty-eight patients were excluded. The remaining 57 patients were divided into three groups: group 1, 26 patients without trauma as control; group 2, 22 patients with trauma but without evidence of FES; and group 3, nine patients with trauma and evidence of FES. Six of 26 patients in group 1 and nine of 22 patients in group 2 exhibited fat droplets in alveolar macrophages, whereas three of nine patients of group 3 had not. This study suggests that (1) presence of fat droplets in alveolar macrophages is not a reliable method for diagnosis of FES after long bone trauma, and (2) many conditions are associated with fat droplets in alveolar macrophages.

Sixteen patients with clinical stage II melanoma of unknown primary site (regional lymph node metastasis) were followed up between 1978 and 1988. The 5-year survival rate was 47%. These results seem to parallel those for stage II disease with known primary tumor sites, as has been observed in other data from the literature. The hypotheses put forward to explain such lesions are the spontaneous regression of the primary tumor, and the onset of primary malignant melanoma in the lymph nodes.

In a multicenter study involving the five Orthopaedic Services of the COC, 57 patients with Kienböck's disease were reviewed 90% were treated surgically. The most common operations were ulna lengthening (30 cases) and lunate resection (11 cases). The most frequent indications or surgery were pain and stiffness of the wrist. Radiological changes are classified according to Decoulx. For evaluating post-operative radiological changes, however, the authors use different criteria ulna lengthening and lunate resection improved pain and mobility in 75% of cases. This study shows that lunate resection is a valid operation in the treatment of Kienböck's disease.

The neurological signs, the cerebral CAT scan aspects and the ocular problems seen in five cases of acute methanol poisoning are reported; these were, respectively, coma requiring assisted ventilation, convulsions, hypotonicity, hypodensity of the putamen, and amaurosis and papillary oedema. The simplified acute physiologic score varied from 11 to 26; the value of 26 was observed in the only death of the series. Pathogenesis of the metabolic acidosis, as well as the different parts played by formic acid, lactic acid and ketone bodies are discussed. A normal or lowered serum potassium in a case of unexplained metabolic acidosis associated with an osmotic gap should make one think of the diagnosis. Macrocytosis, an indirect sign of folic acid deficiency, was in favour of a poor prognosis. The treatment included early gastric lavage, alkalinization, blocking of the metabolism of methanol by ethanol and haemodialysis with a bicarbonate dialysate enriched in ethanol; this corrected the acidosis and permitted the elimination of the toxic metabolites (clearance of methanol: 159 ml X min-1; half-life of methanol during purification: 3.46 +/- 1.32 h; quantity extracted: 246 g). The possible advantages of 4-methyl-pyrazol and alkyldiol derivatives need further confirmation.

The COC (Orthopedic Society of Charleroi) has presented an analysis of operated cases. We have taken 326 files into account. The pre-operative evaluation is based upon the classification by Tubiana, Michon and Thomine. The analysis pays special attention to the post-operative results in terms of several factors: the age, the stage of illness, the extent of illness and the improvement. For this final summing up, we put forward criteria which for us are better in the evaluation of the final result.

A new case of oxytocin-induced water intoxication is reported in a 30 year old gravid woman. The severe symptoms of this uncommon complication are principally neurological; biological signs are a hyponatraemia with low plasma osmolality. Usually, biological and clinical signs are rapidly cleared up by treatment, but maternal death or neonatal water intoxication may occur. Such accidents must be prevented by clinical monitoring, watching out for alarm signals (oliguria is always found, resulting from the effect of oxytocin on the kidney), minimum fluid and proportional salt intakes, careful monitoring of oxytocin infusion rates, facilitated by the use of a constant flow-rate pump.

Twenty-one patients with scaphoid fractures treated by internal fixation with the Herbert screw are reviewed. Nine patients presented acute fractures and twelve had fractures with delayed or non-union. The results of these two kinds of lesions are analyzed following the criteria established by Herbert and Fisher in 1984. This type of internal fixation gives excellent results in isolated lesions of the scaphoid provided it is correctly executed.

A 26-year-old man with hypereosinophilic syndrome who had initial neurologic, cardiac, and pulmonary dysfunction, high eosinophil count, thrombocytopenia, and bone marrow fibrosis had only a transient response to conventional treatment with corticosteroids and hydroxyurea. He therefore received human lymphocyte antigen-identical allogeneic bone marrow transplantation (BMT) after conditioning with cytoxan and fractionated total body irradiation. Hematologic recovery was prompt, with normalization of blood counts and bone marrow. The patient died less than 3 months after transplantation from diffuse cytomegalovirus infection. Potential interest of BMT in patients with resistant hypereosinophilic syndrome and features of poor prognosis is discussed.

An electrophoretic analysis of three enzymatic loci (Got-1, Ldh-A and Ldh-B) has shown that examination of Got-1 alleles allows unambiguous identification of L. muralis and L. hispanica in areas where the two species are sympatric and not identifiable by classical techniques of systematics. At the Ldh-A locus, one allele is common to both species, but a second allele is L. muralis specific and a third one is L. hispanica specific.

A 32 year-old woman after voluntary intoxication with methanol presented, after coma with metabolic acidosis, a prolonged parkinsonian syndrome improved by L-dopa. Initial findings were areflexia and electromyographic signs of neurogenic atrophy of lower limbs. A moderate decrease in visual acuity was associated with altered visual evoked potentials indicating a global lesion of the optic tracts. CT scan during the first few days showed symmetrical low densities areas in the putaminal regions, which unchanged 18 months later. This case can be compared with the rare reported cases with extrapyramidal signs, EMG tracing evidence of peripheral neuropathy and analogous images on CT scanning. The clinical sequelae and CT scan imaging anomalies are the consequence of the characteristic lesions of methanol intoxication, in which the role played by circulatory disorders and that related to the action of the toxic substance itself on nerve cells remains a debatable subject.

Between 1977 and 1982, fifty cases of post-traumatic fat embolism were treated in a general intensive care unit. Average age of patients was 25.5 +/- 13 years; there was no male majority. Mean free interval was 39 +/- 27 h. 12 cases (24%) had single fractures and 38 (76%) multiple fractures. Forty-four patients had a fractured femur. Thirty-two patients presented the complete clinical syndrome with general, respiratory, neurological and cutaneous signs. Thrombocytopaenia and hypocholesterolaemia were the biological signs most often seen. In forty-four patients, orthopaedic treatment consisted of immediate immobilization, usually with traction. Twenty-six patients were reoperated on: intramedullary nail for twenty patients, plate for the other six. Fat embolism appeared in spite of surgery in six cases; it worsened after surgery in six others. Seven patients had per- or postanaesthetic problems. Fourteen per cent of patients died. The decrease in mortality was mainly due to an improvement in mechanical ventilation techniques. Early surgical fixation remained the rule if there was no serious respiratory distress or haemodynamic instability, although it did not seem to change the mortality rate in this group of patients.

Auditory and somatosensory EPS obtained after median nerve stimulation are an interesting approach for the central nervous system investigation. However, there are some problems of interpretation during the first year of life, related to the maturation of the nervous system. We studied 20 severely comatose children aged 8 months to 15 years, admitted in an intensive care unit. Most of them were intubated, mechanically ventilated and received high doses of barbiturates. Coma was related to severe head injury, meningitis, encephalitis, Reye syndrome, malignant hyperthermia, cerebral lymphoma. Normal EP are correlated with a good recovery. Patients with abnormal EP may die or exhibit neurological sequelae. The absence of somatosensory EP is correlated with a bad outcome and is generally related to cerebral oedema. Appreciation of the prognosis in comatose children may be improved by repeated determination of auditory and somatosensory EP.

The authors report 7 cases of acute pulmonary edema in acute carbon monoxide poisoning. Hemodynamic data suggest existence of a myocardial failure as a possible cause of these pulmonary edema and indicate caution for volemic expansion during the treatment of shock in carbon monoxide poisoning.

A 73 years old patient, treated with Amiodarone for ventricular tachycardia, ingested 6 000 mg of Amiodarone. This did not induce hemodynamic troubles or aggravation of ventricular arrhythmia. Treatment included a gastric lavage and purging at the third hour. Plasma assay revealed a concentration of 3.69 mg/l at the fourth hour. Their evolution can be described as the sum of two exponentials. The half-life of the first exponential is 4.9 hours ; the half-life of the second one is 544 hours. Amiodarone is an antiarrhythmic agent of high safety.

Unlabelled: Pulmonary gas exchange was continuously measured in 13 mechanically ventilated patients during 24 hemodialyses for acute renal failure. Minute-ventilation was maintained constant by controlled ventilation and gas exchange was continuously measured by a mass-spectrometer system. Three groups were compared: a cuprophan membrane with an acetate dialysate; a polyacrilonitrile membrane (PAN) with an acetate dialysate; and PAN with a bicarbonate dialysate. Arterial PO2 and the O2 alveolar-arterial gradient were the same regardless of the membrane used. [H+] mildly decreased with all dialysates used. Arterial PCO2 decreased only with the acetate dialysate. O2 consumption increased, up to 20 +/- 5% of the initial values during hemodialysis, and remained increased during the two hours following the hemodialysis. Respiratory exchange ratio was lower after than before the hemodialysis., In Conclusion: the maintenance of a constant minute ventilation prevented hemodialysis induced hypoxemia. VO2 increased during hemodialysis.