Dementia: a systematic approach to identifying reversible causes

The development of FAST is of great importance to clinicians in identifying possibly remediable complications of Alzheimer's disease and distinguishing them from the characteristic progression of the illness. Premature loss of speech in an otherwise uncomplicated Alzheimer's-type presentation should lead the clinician to strongly suspect focal cerebral pathology, especially cerebral infarction.     

Non-ulcer dyspepsia: potential causes and pathophysiology

Dyspepsia, defined as chronic or recurrent upper abdominal pain or nausea, is a common occurrence. Dyspepsia without an ulcer (non-ulcer dyspepsia) is diagnosed in patients at least twice as often as peptic ulceration. Diseases that may present with similar symptoms include gastroesophageal reflux, biliary tract disease, chronic pancreatitis, and irritable bowel syndrome. A careful history and physical examination, supplemented by selected tests, usually lead to a correct diagnosis. The pathogenesis of non-ulcer dyspepsia remains unknown. Gastric acid secretion, duodenogastric reflux, psychological factors, environmental exposures, and heredity probably do not play a major role. Some patients may have motility disturbances, but whether these disturbances cause dyspepsia is unknown. Campylobacter pylori infection and associated gastritis are common in non-ulcer dyspepsia, but their etiologic role is controversial, as is the importance of chronic duodenitis. By recognizing the heterogeneity of patients who present with non-ulcer dyspepsia, more rational management may be possible. Although an empiric trial of antacids or H2 blockers has been recommended to treat dyspepsia, most controlled trials show that although these substances reduce severity of symptoms, they are no more effective than placebos in non-ulcer dyspepsia.     

Fecal incontinence: a practical approach to evaluation and treatment

Fecal incontinence is a common problem and can have a major impact on the quality of life of those affected. Various disease processes affecting stool consistency, rectal sensitivity, or the anal sphincters can cause fecal incontinence. Obstetric trauma is now known to be a major cause of sphincter dysfunction. The evaluation of the patient with incontinence helps to determine the choice of therapy-medical or surgical. The two most important tests are anorectal manometry, which provides information on sphincter pressures, and rectal sensation, and anal endosonography, which is currently the test of choice for defining the anatomy of the anal sphincters. The choice of therapy depends on the etiology of incontinence, the anatomy of the sphincters, and also on the effect of incontinence on the quality of life of the patient. Control of diarrhea, regardless of the cause, should be attempted first. Biofeedback therapy is effective in the majority of patients and is particularly attractive because it is safe and well tolerated. Surgery is offered when medical therapy is unsuccessful or when the etiology is thought to respond best to surgery, such as in postobstetric trauma. Sphincter repair, for treatment of selective sphincter defects, is the best surgical option. Neoanal sphincters and implanted artificial sphincters are far less attractive because of technical difficulties and low success rate.     

Palpitations: A proper evaluation and approach to effective medical therapy

Palpitations are a common complaint seen in the outpatient setting and the vast majority are benign, although they are occasionally a manifestation of potentially life-threatening conditions. We offer a step-wise guide to the evaluation and management of these patients with the primary goal to identify patients at highest risk for serious arrhythmias. We offer a brief overview of effective management of the varied causes of palpitations.     

A review of causes and systemic approach to cardiac troponin elevation

The first American College of Cardiology/European Society of Cardiology task force published recommendations for a universal definition of myocardial infarction (MI) in 2000 based on the measurement of troponin (Tn). Although this rapid and highly sensitive blood test is certainly valuable in the appropriate setting, its widespread use in variety of clinical scenarios may lead to the detection of Tn elevation in absence of thrombotic acute coronary syndrome. In 2007, the joint European Society of Cardiology/American College of Cardiology Foundation/American Heart Association/World Heart Federation task force proposed a new definition for acute MI based on detection of Tn and associated clinical evidence. The goal of this article is to review the universal definition of acute MI and to differentiate type 1 MI, type 2 MI, and non-acute coronary syndrome Tn elevations. The prognosis and a clinical approach to this differential diagnosis will be developed.     

Constipation: Initial evaluation and diagnostic approach

Constipation is a common gastrointestinal symptom and affects about 20% of the general population. This symptom can reflect a vast array of problems, from inadequate fiber intake to colonic dismotility function. Identifying chronic constipation subtypes on underlying physiology guides the therapeutic choices. Chronic constipation subtypes includes: slow-transit constipation, functional constipation, irritable bowel syndrome with constipation predominance and pelvic floor dysfunction. The most useful tests for the evaluation of those patients are the colonic transit time with radiopaque markers and anorrectal manometry with balloon expulsion test. Patients with both normal tests have either functional constipation or irritable bowel syndrome with constipation. Subjects with a delayed colonic transit and normal anorectal manometry maybe classified as colonic inertia. Pelvic floor dysfunction maybe suspected if the patient had an abnormal manometry with failure to expulse de balloon. Initial treatments of chronic constipation are dietary fiber and medicinal bulk. Subsequent treatments if fiber is not successful or tolerated would include saline osmotic laxatives such as lactulose and polyethylene glycol, or stimulants like senna or bisacodyl. For patients with pelvic floor dyssynergia biofeedback therapy is the first therapeutic option. In this article we present an overview of current diagnostic tools for patients with chronic constipation.     

An approach to echocardiography in hypertrophic cardiomyopathy and other causes of LVH

Hypertrophic cardiomyopathy (HCM) is the most prevalent genetic cardiovascular disease with a prevalence of 1:500 in the general population. Its identification is of critical importance as it is a common cause of sudden death in the young and can lead to considerable morbidity, including heart failure and atrial fibrillation. There are several conditions that can mimic the phenotypic appearance of HCM on echocardiography. Echocardiography remains an invaluable tool in both initial diagnosis and regular surveillance of patients with this condition. Although no single echocardiographic parameter is ideal, a structured and comprehensive assessment of cardiac structure and function will provide invaluable clues to the diagnosis and often hint towards an alternate diagnosis. The purpose of this review is to reassess the typical echocardiographic features of HCM and to highlight echocardiographic features that may help to distinguish other causes of left ventricular hypertrophy (LVH).     

Methods and potential biomarkers for the evaluation of endothelial dysfunction in chronic kidney disease: A critical approach

The impressive cardiovascular morbidity and mortality of chronic kidney disease (CKD) patients is attributable in a significant proportion to endothelial dysfunction (ED), arterial stiffness, and vascular calcifications. Abnormal vascular reactivity in these patients is more pronounced compared with other high-risk populations, but remains undiagnosed in the usual clinical setting. We briefly review the most important causes and risk factors of ED, oxidative stress, and inflammation related to arterial stiffness. We describe the main methods of ED investigation and the importance of using potential biomarkers together with classic techniques for a more comprehensive assessment of this condition. These methods include evaluation of: forearm blood flow by plethysmography, skin microcirculation by laser Doppler, and flow-mediated vasodilation by Doppler ultrasound imaging. Applanation tonometry is an easy-to-handle tool that allows a clinically reliable assessment of arterial stiffness and is also useful in quantifying endothelium-dependent and -independent vascular reactivity. We also discuss the diagnostic and therapeutic impact of new markers of ED in the CKD population. Improvement of endothelial function is an important challenge for clinical practice, and there are relatively few therapeutical strategies available. Therefore, a combined biomarker and bedside investigational approach could be a starting point for developing optimal therapeutic tools.     

Proteinuria in diabetic nephropathy: Treatment and evolution

Diabetic nephropathy is characterized by increased urinary albumin excretion and loss of renal function. Increased urinary albumin (proteinuria) is a key component of this disease. Previously, its development led to end-stage renal disease with increased mortality and morbidity for diabetic patients versus nondiabetic patients. Several treatment strategies currently exist that can prevent, slow, and even reverse diabetic nephropathy. New trials suggest that a multidisciplinary approach focused on optimizing metabolic and hypertensive control, in addition to the use of angiotensin-converting enzyme inhibitors or angiotensin 2 receptor antagonists, is effective in halting the progression of disease. Screening and implementation of these strategies is needed to reverse the epidemic of diabetic renal disease.