Diagnosis and classification of erythrocytoses and thrombocytoses

An erythrocytosis describes an increased peripheral blood packed cell volume (PCV) and is deemed to be absolute or apparent depending on whether or not the measured red cell mass (RCM) is above the reference range. This reference range must be related to the individual's height and weight to avoid erroneous interpretations using ml/kg total body weight expressions in obesity. Absolute erythrocytoses are divided into primary, where the erythropoietic compartment is intrinsically abnormal, secondary, where the erythropoietic compartment is normal but is responding to external pathological events leading to an increased erythropoietin drive, and idiopathic, where neither a primary nor a secondary erythrocytosis can be established. Both primary and secondary erythrocytoses have congenital and acquired forms. The only form of primary acquired erythrocytosis that has been defined is the clonal myeloproliferative disorder, polycythaemia vera (PV). Modified diagnostic markers for PV are proposed. Thrombocytoses can be classified into primary, where megakaryopoiesis is intrinsically abnormal, secondary, where megakaryopoiesis is normal but increased platelet production is a reaction to some other unrelated pathology, and finally idiopathic. This latter new group would be used for patients not satisfying the criteria for primary or secondary thrombocytoses, if these were more precise and rigidly used than currently is the case. While theoretically congenital and acquired forms of primary and secondary thrombocytoses might exist, only one cause of secondary congenital thrombocytosis has been established, and primary congenital thrombocytosis has not yet been precisely defined. Primary (essential) thrombocythaemia (PT) is one of the forms of primary acquired thrombocytoses. The diagnostic criteria of PT traditionally involve the exclusion of secondary thrombocytoses and other myeloproliferative disorders but marrow histology could hold a key positive diagnostic role if objective histological features of PT were agreed.     

Diagnosis and treatment of head and facial pain

The symptom headache is very frequent. Most frequently headache is the leading symptom of a primary headache syndrome such as migraine or tension-type headache. Sometimes it is caused by another disease. In everyday clinical practice it is important to diagnose and treat primary headaches properly. It is even more important not to miss a secondary headache, which is rare, but if misdiagnosed could conceal life-threatening conditions. This review provides an overview of the clinical picture, diagnostic procedures and treatment strategies of frequent headache syndromes such as migraine, tension-type headache, medication overuse headache, trigeminal autonomic cephalgias and trigeminal neuralgia. This is followed by a brief summary on symptomatic headache caused by non-neurological diseases as well as on diagnostic procedures and management of headache in the emergency situation.     

Replication and Inhibitors of Enteroviruses and Parechoviruses

The Enterovirus (EV) and Parechovirus genera of the picornavirus family include many important human pathogens, including poliovirus, rhinovirus, EV-A71, EV-D68, and human parechoviruses (HPeV). They cause a wide variety of diseases, ranging from a simple common cold to life-threatening diseases such as encephalitis and myocarditis. At the moment, no antiviral therapy is available against these viruses and it is not feasible to develop vaccines against all EVs and HPeVs due to the great number of serotypes. Therefore, a lot of effort is being invested in the development of antiviral drugs. Both viral proteins and host proteins essential for virus replication can be used as targets for virus inhibitors. As such, a good understanding of the complex process of virus replication is pivotal in the design of antiviral strategies goes hand in hand with a good understanding of the complex process of virus replication. In this review, we will give an overview of the current state of knowledge of EV and HPeV replication and how this can be inhibited by small-molecule inhibitors.     

Background and current knowledge of Chlamydia pneumoniae and atherosclerosis

Attributes of Chlamydia pneumoniae of potential importance to a relationship with atherosclerosis are described. Among these are that C. pneumoniae is not new. It is unique. It is a pathogen with which everyone is infected, and it is difficult to treat. It causes immunopathology, myocarditis, and endocarditis and chronicity is a hallmark of Chlamydia infection. Current knowledge of the relation of C. pneumoniae and atherosclerosis comes from observational (e.g., seroepidemiology and tissue studies) and experimental studies. The limitations of the serologic studies of chronic infection are noted as is the conclusive demonstration of an association of C. pneumoniae and atherosclerosis by the repeated and frequent finding of the organism in atherosclerotic tissue. Experimental studies are needed to determine if the association is causal. Such studies should include animal models, basic mechanisms, and secondary prevention antibiotic treatment trials.     

Recent knowledge of the structure and function of lactoferrin and ferritin

A survey of recent knowledge on structure and importance of lactoferrin and ferritin is given. Lactoferrin is a symmetrically constructed glycoprotein which appears in the milk and in the body fluids and develops a bacteriostatic efficiency on account of the ability to Fe-binding together with other factors such as the IgA. In a particularly high concentration it is contained in the colostral milk of the woman. In the milk of the cattle the content is small. In the neutrophil granulocytes it is of importance for the functional ability in the phagocytosis. The ferritins are spherically constructed molecules which possess channels through which Fe-ions (up to 4,500 pro molecule) can be taken up or taken off. The ferritin content in the serum is correlated with the Fe-content of the liver and is dependent upon age as well as the Fe-supply. It decreases in Fe-deficiency: it increases in iron overload, in infectious diseases, in inflammation as well as in tumour development.     

Evaluation and management of solitary and multiple pulmonary nodules.

The evaluation and management of a patient with an SPN is guided by principles that were derived from earlier surgical studies. Stability or no growth for at least 2 years, the presence of calcium in characteristic patterns, and age less than 35 years without any associated risk factors are reliable indicators of a benign process. Fluoroscopy and localized tomography are helpful in evaluation of an SPN. If the nodule is still considered indeterminate, CT scanning, with the use of thin section cuts through the nodule, is now widely employed. If calcium is present in a characteristic pattern, the nodule is considered benign. If the nodule is very dense or more dense than a phantom reference nodule, the nodule has a high likelihood of being benign. Nodules that are less dense than the phantom nodule are indeterminate, and approximately 25% of these nodules will be benign. Computed tomography scan of the chest and upper abdomen is indicated in patients with a previous history of malignancy or when there is a high suspicion that the nodule is malignant. The further evaluation and management of SPNs that are indeterminate after CT examination are controversial. Some recommend tissue biopsy via transbronchoscopic or transthoracic approach, whereas others recommend immediate thoracotomy. Observation is indicated in certain situations when the chance of malignancy is quite low, the patient is not an operable candidate, or when the patient refuses further invasive evaluation. The physician's role in the management of a patient with an SPN is to educate and advise. The physician must be aware of the patient's anxieties, fears, and attitude and provide an opportunity for active participation by the patient in the decision-making process. Multiple pulmonary nodules are most commonly encountered in patients with metastatic disease to the lungs. Other less commonly encountered diseases that present as multiple pulmonary nodules include infections, arteriovenous malformations, Wegener's granulomatosis, and lymphoma. The evaluation and management of the patient with multiple pulmonary nodules are usually guided by the history, physical examination, and laboratory findings.     

Diagnosis and Management of Necrotizing Fasciitis of the Head and Neck

Necrotizing fasciitis is a rapidly progressing and life-threatening soft tissue infection that often affects the abdominal wall, perineum, or extremities following surgery or trauma. It predominantly occurs in elderly and immunocompromised patients. It is rarely seen in the head and neck region. Necrotizing fasciitis of the head and neck carries high rates of morbidity and mortality. Symptoms usually develop quickly and well-timed diagnosis is critical to optimizing outcome. Diagnosis is based on a combination of clinical history, Gram staining and culture, imaging and surgical exploration. Early and aggressive surgical management and urgent parenteral antibiotic therapy are critical to optimizing outcome.     

Use and limitations of clinical and radiologic diagnosis of pneumonia

Pneumonia remains foremost a clinical diagnosis. However, symptoms of lower respiratory infection, including fever, cough, purulent sputum, dyspnea, and pleuritic pain as well as the clinical findings of tachypnea, tachycardia, hypoxemia, and auscultatory signs of consolidation, are not unique to pneumonia. Chest radiographs are therefore routinely required to confirm the clinical suspicion of pneumonia. This article discusses the limitations and pitfalls in the clinical and radiographic diagnosis of both community-acquired pneumonia and hospital-acquired, especially ventilator-associated, pneumonia. Given the difficulties of clinical diagnosis in pneumonia, empiric antibiotic treatment often is used. Inherent in the use of empiric therapy is the assumption that a favorable clinical response indicates both that pneumonia is present and that the empiric treatment is adequate. An accurate assessment of the normal, expected response of pneumonia to antibiotic therapy is therefore crucial. A discussion of the clinical response to treatment concludes the article.     

Diagnosis and treatment of chronic and recurrent diverticulitis

In Western countries the prevalence of diverticular disease has increased over the past century. Although, most patients remain asymptomatic, among those who experience an attack of diverticulitis, one-third will have recurrent symptoms, and a further third will have a subsequent episode. The indications for surgery after treatment of acute diverticulitis is still under debate. Uncomplicated disease less commonly as thought, progresses to a life threatening situation such as free perforation. Among those who develop complicated diverticulitis, it is often their first presentation. Fistula to the urinary tract often require surgery; however, complicated disease such as an abscess or phlegmon can be managed conservatively and subsequent surgery is selective depending on the recovery from the initial episode. Patients with chronic diverticular disease (persistent pain in the absence of inflammation) have greatly improved quality of life with surgery. The question of greater virulence of disease among young patients may no longer be true and recommendations for surgery may parallel that of older patients. Immunocompromised patients should have definitive surgical therapy early on in the course of the disease. Right-sided disease remains uncommon in the Western world and a conservative approach in the absence of free perforation is recommended. In right-sided disease and in young patients, misdiagnosis is common. In the elective setting, a laparoscopic approach is rapidly becoming preferred because of less morbidity and shorter hospital stay. The treatment of diverticular disease is rapidly undergoing reevaluation, and novel therapies and increased conservative approaches are evolving. Prospective randomized trials are needed, but remain difficult owing to the uncertain natural history of the disease.     

Diagnosis and managemnet of endometriosis of the colon and rectum

Colon and rectal endometriosis is a relatively rare entity that may have a wide array of clinical symptomatology and radiographic findings. Thirty-two patients with a diagnosis of colon or rectal endometriosis were seen and treated at the Ferguson Clinic between 1960 and 1986. Diagnostic, pathologic, and therapeutic findings were reviewed. All patients, except one, had large-bowel symptoms. Ten patients had previous histories of pelvic endometriosis. When endometriosis in the colon causes significant symptoms or a neoplasm cannot be ruled out, partial colectomy is recommended. If pelvic endometriosis is extensive, removal of the endometriomas and reproductive organs should be entertained concurrent with bowel resection. Hormonal manipulation may be attempted in certain select patients with very close follow-up. Read at the meeting of the American Society of Colon and Rectal Surgeons, Washington, D.C., April 5 to 10, 1987.     

Osteoporosis and the intake of meat and fish

Usual intake of meat and fish may not be a risk factor or a protective factor for osteoporosis. When the large proportion of protein intake depends on the animal meat, it is possible to give adverse effects on bone metabolism. Fish is an important source of vitamins A and D. Although the adequate intake of these vitamins is indispensable for healthy bone, excessive intake of vitamin A would be harmful to the skeletal system.     

我国骨关节结核诊治的回顾与展望

骨关节结核是危害人们健康的严重感染性疾病,近95％由他处结核病继发而来.罹患骨关节结核疾病后几乎均将致残,严重影响人们的健康、工作和生活.建国以来在党和国家的关心和支持下,骨关节结核的诊治水平取得了长足进步.时至今日,由于多种原因,学科发展和被重视程度受到一定的制约,同整个医疗行业的发展不相适应.回顾过去,展望未来,我们需要重新审视骨关节结核的诊治方法,努力推进骨关节结核诊疗技术的科学发展.     

Superficial and peripheral vascular malformations. Role of interventional radiology and of embolization]

Embolization plays a major role in the management of arteriovenous malformations and fistulae on one hand, and of venous malformations and cystic lymphangiomas on the other hand. The treatment of arteriovenous fistulae today resorts to a primarily endovascular technique including the insertion under controlled flow of a releasable balloon or of a metallic coil positioned in the area of the fistula. Of course, this is possible only if there is a gap between the arterial and venous pathways. When the vessels are in direct contact, surgery must be preferred. In cases of arteriovenous malformations, embolization currently plays a great role; either it is performed with particles in the immediate preoperative period, two or three days before surgery, or as a definitive curative treatment with a polymerizing substance applied in situ. The use of flexible microcatheters allows penetrating into most of these vascular malformations and scattering polymerizing material all over the shunting areas. This is possible for superficial malformations, as is now performed, for instance, for brain AVMs. This embolization obviously can be contemplated only after a decision to treat these malformations has been made, knowing that they may be silent or acquire an uncontrollable evolution potential. This therefore is a collegial decision. As far as venous hemangiomas and cystic lymphangiomas are concerned, the greatest basic therapeutic means today is direct puncture and the in situ injection of a fibrosing substance under angiographic monitoring: the use of Ethibloc or, failing this, of absolute alcohol, has dramatically transformed the prognosis of these malformations, for which the surgical difficulties are well known (easy rupture, blood that often fails to coagulate, life-long progressive evolution).(ABSTRACT TRUNCATED AT 250 WORDS)     

Current diagnostics and therapy of the overactive bladder and urge incontinence

Urinary incontinence affects millions of people worldwide and also represents a social problem. Costs of urinary incontinence and overactive bladder are very high. Urge incontinence is the involuntary loss of urine associated with a strong desire or urge to urinate. There are two types of urge incontinence: One is associated with involuntary detrusor contractions leading to a loss of urine, the other is characterized by a hypersensitive bladder in which micturition reflexes are induced due to an increased afferent activity. It is important to distinguish between an idiopathic type of urge incontinence and a symptomatic type possibly caused by infections, tumours, bladder stones or foreign bodies. Diagnostics is based on a careful medical history, clinical examination and urodynamic evaluation. The use of a voiding diary is necessary. Current agents for drug therapy rely upon their anticholinergic properties. Their use is limited by side effects such as blurred vision, dizziness, constipation and dryness of the mouth. Additionally, patients refractory to anticholinergic medication can be treated by endoscopic direct injection of botulinum toxin into the detrusor muscle. These patients can also be treated by intravesical application of vanilloid derivatives in the bladder leading to a desensitization of bladder sensory fibers. In some cases of refractory urge incontinence, electrical neuromodulation is effective. Other pharmacological approaches could be selective b-adrenoceptor agonists, calcium antagonists and potassium channel openers, but these substances are not yet available for clinical use.     

Cooperation of B- and T-lymphocytes of the human in vitro and in vivo

It is reported on the experimental proofs for the existence of a cooperation of different populations of lymphocytes in man. Regulatory lymphocytes play a part in the regulation of the synthesis of immunoglobulins by polyclonally stimulated B-lymphocytes, in the generation of killer-T-cells and in the regulation of the DNA-synthesis by mitogenically stimulated T- and B-cells. Typical helper- and suppressor-effects may be proved. Disturbances of lymphocytic interactions may be a cause for the development of immune deficiency diseases. It is very probable that also in several chronic infections a dysfunction of regulatory T-lymphocytes is present.     

Aetiology and physiopathology of preeclampsia and related forms

Preeclampsia, a pregnancy-specific syndrome characterized by hypertension, proteinuria and oedema, resolves on placental delivery. Its pathogenesis is thought to be associated to a hypoxic placenta. Placental hypoxia is responsible for the maternal vascular dysfunction via the increased placental release of anti-angiogenic factors such as soluble flt1 and endoglin. These soluble receptors bind VEGF, PLGF and TGFbeta1 and 3 in the maternal circulation, causing endothelial dysfunction in many maternal tissues. Despite these recent and important new molecular findings, it is important to consider that normal pregnancy is also characterized by systemic inflammation, oxidative stress and alterations in levels of angiogenic factors and vascular reactivity. Both the placenta and maternal vasculatures are major sources of reactive oxygen and nitrogen species which can produce powerful pro-oxidants that covalently modify proteins and alter vascular function in preeclampsia. Finally, the recent demonstration of activating auto-antibodies to the Angiotensin 1 receptor that experimentally play a major pathogenic role in preeclampsia further indicates the pleiotropism of aetiologies of this condition.     

Genetic and epigenetic aspects of initiation and progression of hepatocellular carcinoma

Hepatocellular carcinoma(HCC) is a primary cancer of the liver that is predominant in developing countries and is responsible for nearly 600000 deaths each year worldwide. Similar to many other tumors, the development of HCC must be understood as a multistep process involving the accumulation of genetic and epigenetic alterations in regulatory genes, leading to the activation of oncogenes and the inactivation or loss of tumor suppressor genes. Extensive research over the past decade has identified a number of molecular biomarkers, including aberrant expression of HCCrelated genes and microRNAs. The challenge facing HCC research and clinical care at this time is to address the heterogeneity and complexity of these genetic and epigenetic alterations and to use this information to direct rational diagnosis and treatment strategies. The multikinase inhibitor sorafenib was the first molecularly targeted drug for HCC to show some extent of survival benefits in patients with advanced tumors. Although the results obtained using sorafenib support the importance of molecular therapies in the treatment of HCC, there is still room for improvement. In addition,no molecular markers for drug sensitivity, recurrence and prognosis are currently clinically available. In this review, we provide an overview of recently published articles addressing HCC-related genes and microRNAs to update what is currently known regarding genetic and epigenetic aspects of the pathogenesis of HCC and propose novel promising candidates for use as diagnostic and therapeutic targets in HCC.     

Aging of veins and venules

There is a distinction between natural ageing and excessive ageing. The problem is not only vascular, it is above all interstitial conjunctival; it is located in the trunk wall and in the initial collector walls; the capillary-venular section is, from this point of view, just a unit of structure and function. The clinical and anatomopathological aspects of venous ageing are known: they are those of phlebosclerosis and deposits of proteoglycanes, the lesions are non-homogenous, dispersed and constantly changing. The elderly patient lives in a state of stasis. Stasis creates exaggerated and uncontrollable histangic neogenesis, it is the backcloth of "micro-angiopathy of senescence", but if the membrane thickens, it is in order to counter the ill effects of stasis; it is a control reaction not one caused by lesion. It is vital to establish an analogy between vascular ageing and "plastic" ageing, the process of polymerization is the same and we shall produce the evidence of this on another occasion.     

Diagnosis and treatment of pouchitis

Total proctocolectomy with ileal pouch-anal anastomosis is the surgical procedure of choice for the management of ulcerative colitis. Pouchitis, a non-specific inflammation of the ileal reservoir, is the most frequent complication that patients experience in the long-term. Diagnosis should be made on the basis of clinical, endoscopic and histological aspects. The Pouchitis Disease Activity Index (PDAI) represents an objective and reproducible scoring system for pouchitis: active pouchitis is defined as a score > or = 7 and remission as a score < 7. About 15% of patients develop a chronic disease. Treatment of pouchitis is empirical, and very few controlled studies have been carried out. Antibiotics, particularly metronidazole and ciprofloxacin, are the treatment of choice. Chronic pouchitis may benefit from a prolonged course of a combination of antibiotics. Highly concentrated probiotics are effective for both prevention of relapses and prevention of pouchitis onset. There is no convincing evidence of the efficacy of other therapeutic agents.