Major neurological disease and occupational exposure to organic solvents.

Five patients are described who presented with major organic brain disease affecting one or more of pyramidal and extrapyramidal tracts, cerebellum, and higher cortical functions. All had a history of 10 years or more of regular occupational exposure to solvents in confined spaces, three in painting inside ships and the others in weapons maintenance and printing. All had been regularly exposed to high air vapour peaks as well as to skin contamination. Four showed some evidence of improvement after the exposure ceased. None was initially suspected of having a toxic encephalopathy by the consultant to whom he was referred. The spectrum of neurological disease presented by these men mirrors closely that described in solvent abusers. All were forced by illness to retire from their work, a circumstance which might have in the past have led to such conditions being missed in cross-sectional studies, which in general have not shown evidence of major disease. We suggest that when such disease occurs nowadays, its cause is usually not suspected. Further epidemiological study of the problem is necessary.     

Focal areas of decreased echogenicity in the liver at the porta hepatis

Twelve patients are described in whom solitary focal hypoechoic areas in the liver were observed adjacent to the gallbladder and portal vein. These areas were all homogeneously hypoechoic relative to adjacent liver, had variable shapes but well-defined borders, and were less than 4 cm in diameter. These apparent pseudolesions were incidental findings in patients who had no evidence of significant liver disease, metastatic malignancy, or subsequent evidence of developing liver masses. In one patient, a second sonogram done 21 months after one such area was identified showed no change. In another patient, a computed tomogram done to clarify the finding was normal. Solitary hypoechoic areas in the liver at the porta hepatis fitting the above criteria should be interpreted cautiously. When there is no clinical suspicion of focal liver disease, these areas may be dismissed as insignificant or may be followed. If focal liver disease is suspected, the liver should be assessed by an additional method of examination.     

Forensic perioperative nursing. Advocates for justice

Facts and evidence have been negated or lost by the inexperience of health care professionals who are not cognizant of the legal requirements concerning potential criminal cases. In the perioperative setting, policy and procedure should provide guidelines for potential criminal cases based on the key concepts and principles of forensic science. Potential forensic cases and traumatic injuries are not limited to major health care centres. All hospitals should have policies and procedures which outline: traumatic injuries/death, staff responsibilities, details of collecting evidence, documentation, chain of custody. The procedure should also include care of victims, suspected perpetrators as well as family/persons accompanying patient.     

Emergency Management Of Acute Epiglottitis

Epiglottitis, while primarily a disease of childhood, does occur in adults of all ages, often with fatal results. Any emergency physician or family physician should be aware of and able to manage this condition. The disease consists of both local and systemic infection. The causative organism is usually H. influenza - type B, but other organisms have often been implicated. The disease is insidious in nature and may rapidly become fatal. Airway obstruction is the major complication. An otolaryngologist should be called in consultation as soon as the disease is suspected. Tracheostomy is often necessary, and a technique of emergency tracheostomy is described.     

Chronic Lyme disease: the controversies and the science

The diagnosis of chronic Lyme disease has been embroiled in controversy for many years. This is exacerbated by the lack of a clinical or microbiologic definition, and the commonality of chronic symptoms in the general population. An accumulating body of evidence suggests that Lyme disease is the appropriate diagnosis for only a minority of patients in whom it is suspected. In prospective studies of Lyme disease, very few patients go on to have a chronic syndrome dominated by subjective complaints. There is no systematic evidence that Borrelia burgdorferi, the etiology of Lyme disease, can be identified in patients with chronic symptoms following treated Lyme disease. Multiple prospective trials have revealed that prolonged courses of antibiotics neither prevent nor alleviate such post-Lyme syndromes. Extended courses of intravenous antibiotics have resulted in severe adverse events, which in light of their lack of efficacy, make them contraindicated.     

Chronic Lyme disease: the controversies and the science

The diagnosis of chronic Lyme disease has been embroiled in controversy for many years. This is exacerbated by the lack of a clinical or microbiologic definition, and the commonality of chronic symptoms in the general population. An accumulating body of evidence suggests that Lyme disease is the appropriate diagnosis for only a minority of patients in whom it is suspected. In prospective studies of Lyme disease, very few patients go on to have a chronic syndrome dominated by subjective complaints. There is no systematic evidence that Borrelia burgdorferi, the etiology of Lyme disease, can be identified in patients with chronic symptoms following treated Lyme disease. Multiple prospective trials have revealed that prolonged courses of antibiotics neither prevent nor alleviate such post-Lyme syndromes. Extended courses of intravenous antibiotics have resulted in severe adverse events, which in light of their lack of efficacy, make them contraindicated.     

Detection of stress fractures in athletes and nonathletes

Stress fractures are considered a relatively common athletic injury. Some authors also feel this disorder may be overlooked in many nonathletic patients. Three cases of stress fractures are presented. All had classical clinical pictures; however, two were athletes and one was not. The athletes' stress fractures were suspected early in the disease evolution, confirmed with a bone scan and proper care instituted to prevent extended morbidity. The nonathlete's case was misdiagnosed by another practitioner and allowed to progress to the level of a true fracture. Extended morbidity followed this case. The infrequent report of nonathlete stress fractures in the literature may have played a major role in this oversight. Stress fractures do occur in athletes and nonathletes. The history is the key to making an early diagnosis. Scintigraphy (bone scan) or plain films may be used to confirm the diagnosis and rule out other disorders.     

The role of transbronchial needle aspiration in the diagnosis of bronchogenic carcinoma

BACKGROUND: For many years in the United States transbronchial needle aspiration (TBNA) has been used with flexible bronchoscopy to diagnosis bronchogenic carcinoma, but very few data are available from the United Kingdom. METHODS: All bronchoscopies performed for suspected bronchial carcinoma at Papworth Hospital, Cambridge, United Kingdom, over the last 3 years were reviewed retrospectively. Patients with peribronchial disease, as evidenced by submucosal infiltration or extrinsic compression on bronchoscopy, were selected for TBNA. Patients with computed tomography evidence of subcarinal lymphadenopathy were also included. In total we identified 78 patients: 67 with peribronchial disease and 21 with subcarinal lymphadenopathy. All 78 patients underwent TBNA, and in 8 of these TBNA was performed in 2 sites. RESULTS: Malignancy was confirmed in 66 of the 78 patients. TBNA was positive in 31/66 (47%) of the patients who had proven bronchogenic carcinoma. Additional staging information was obtained in 9/21 patients (42.8%) who underwent subcarinal lymph node aspiration. We also found that TBNA was diagnostic in 1 patient with tuberculosis and 1 with sarcoidosis. There was only 1 important TBNA complication, which was a small pneumothorax. CONCLUSION: In our preliminary experience with selected patients suspected to have bronchogenic carcinoma (based on peribronchial disease or subcarinal lymphadenopathy), we found TBNA a safe and useful tool.     

Palliative care provision in Huntington's disease

There is currently much interest regarding the needs of people affected by non-malignant disease and whether or not these are being met by palliative care services. The evidence available appears to support the conclusion that while there is a general inequality of access, some individuals with non-malignant conditions such as cardiac disease and motor neurone disease are able to access palliative care services more readily than others. Huntington's disease (HD) is a devastating neurological condition of long duration and as such may have a lengthy palliative phase. Consequently, a diagnosis of HD will have a major impact on the quality of life of the affected individual and their family. For carers, an understanding of this challenging disease and its prognosis is essential for the provision of appropriate and effective care. This article reviews the links between HD and palliative care and discusses some of the challenges facing patients, families and health care professionals in adopting a palliative approach in the management of the disease.     

77例SARS院内感染患者临床特征分析

目的 :分析严重急性呼吸综合征 (SARS)患者的临床特征及院内感染特征。方法 :总结 2 0 0 3年 4月16日— 5月 2 8日由天津首例输入性 SARS引起 77例院内感染患者的临床特点及救治体会。结果 :77例中男性 2 7例 ,女性 5 0例 ;平均年龄 (37.7± 13.7)岁。所有患者均有明确的接触史 ,潜伏期 1～ 11d;均表现为发热 ,大部分有干咳、呼吸困难、周身不适、头痛及低氧血症 ,胸部查体可以闻及水泡音和爆裂音 ;80 %的患者出现了淋巴细胞减少 ,部分患者出现转氨酶的轻度升高 ,血肌酐水平正常。连续性 X线胸片检查表现为肺部明显的炎症改变。其中 1例死于进行性呼吸衰竭 ,1人自杀。所有的患者自出现症状后均接受了甲基氢化泼尼松及病毒唑治疗 ,治疗时间为 (18.6± 5 .4 ) d;早期均接受了抗生素治疗 ,无明显效果。结论 :以甲基氢化泼尼松和病毒唑为主的综合治疗对 SARS有较好的疗效。     

Kikuchi's disease: a rare cause of cervical lymphadenitis and fever

Cervical lymphadenitis and fever are common in patients presenting to the Emergency Department (ED). Kikuchi's disease is a rare, self-limited cause of fever and cervical lymphadenitis often misdiagnosed as lymphoma or lupus and inappropriately treated, potentially causing numerous ED visits for unrelieved symptoms. The case described is that of a 29-year-old with persistent fever and cervical lymphadenitis who presented to the ED with a suspected allergic reaction to an antibiotic. The diagnosis of Kikuchi's disease was made in association with nasopharyngeal carcinoma and partial hydatidiform mole. The case highlights the clinical features, diagnosis, and treatment of Kikuchi's disease.     

Salt intake, plasma sodium, and worldwide salt reduction

There is overwhelming evidence that a reduction in salt intake from the current level of approximately 9-12 g/d in most countries of the world to the recommended level of 5-6 g/d lowers blood pressure (BP) in both hypertensive and normotensive individuals. A further reduction to 3-4 g/d has a greater effect. Prospective studies and outcome trials have demonstrated that a lower salt intake is related to a reduced risk of cardiovascular disease. Cost-effectiveness analyses have documented that salt reduction is more or at the very least just as cost-effective as tobacco control in reducing cardiovascular disease, the leading cause of death and disability worldwide. The mechanisms whereby salt raises blood pressure and increases cardiovascular risk are not fully understood. The existing concepts focus on the tendency for an increase in extracellular fluid volume. Increasing evidence suggests that small increases in plasma sodium may have a direct effect on BP and the cardiovascular system, independent of extracellular volume. All countries should adopt a coherent and workable strategy to reduce salt intake in the whole population. Even a modest reduction in population salt intake will have major beneficial effects on health, along with major cost savings.     

Do caffeine-containing analgesics promote dependence? A review and evaluation

OBJECTIVE: Debates about the suspected association between kidney disease and use of analgesics have led to concern about whether caffeine could stimulate an undesirable overuse of phenacetin-free combined analgesics. A committee was asked to critically review the pertinent literature and to suggest guides for clinical practice and for consideration of international regulatory authorities. PARTICIPANTS: A group of international scientists, jointly selected by the regulatory authorities of Germany, Switzerland, and Austria and the pharmaceutical industry. EVIDENCE: All invited experts evaluated relevant literature and reports and added further information and comments. CONCLUSIONS: Caffeine has a synergistic effectiveness with analgesics. Although caffeine has a dependence potential, the potential is low. Experimental data regarding dependence potential for caffeine alone may not correspond to the conditions in patients with pain. Withdrawal is not likely to cause stimulation or sustainment of analgesic intake. For drug-induced headache, no single or combined analgesic was consistently identified as causative, and no evidence exists for a special role of caffeine. Strong dependence behavior was observed only in patients using phenacetin-containing preparations, coformulated with antipyretics/analgesics and caffeine. This finding may have led to the impression that caffeine stimulates overuse of analgesics. SUMMARY: Although more experimental and long-term data would be desirable to show possible mechanisms of dependence and to offer unequivocal proof of safety, the committee concluded that the available evidence does not support the claim that analgesics coformulated with caffeine, in the absence of phenacetin, stimulate or sustain overuse.     

Some considerations of methodology and standardization of apolipoprotein A-I immunoassays

Apolipoprotein A-I (apo A-I) is the major protein of high-density lipoprotein. Compelling evidence suggests that measurement of concentrations of apo A-I in serum may be useful in predicting and assessing ischemic heart disease. The following review of methods of isolation, characterization, and assay of apo A-I has been developed to assess the possibility of standardizing apo A-I immunoassays. We consider the properties of apo A-I that have an effect on its quantification, such as self-association, polymorphism, and stability characteristics. We attempt to review critically the various methods presented, but more information about the physicochemical properties of the protein is required before definitive recommendations can be made.     

Subacute cutaneous lupus erythematosus: a decade's perspective

Based upon the rather large worldwide experience that has been published recently, it would appear that the concept of subacute cutaneous LE as presented in our original reports starting 10 years ago is still a viable one. However, we must now also consider the possibility that these patients will occasionally develop other types of autoimmune disorders such as rheumatoid arthritis and Sj?gren's syndrome and, on occasion, have their skin disease triggered by drugs such as hydrochlorothiazide. However, the majority of these patients will have recurrent skin disease activity and musculoskeletal symptoms as the major manifestations of their illness. Although most of these patients do have a relatively mild disease course, a small percentage seem to be at risk for developing potentially life-threatening complications of systemic LE. The future challenge in this area lies in identifying prognostic features that may correlate with this more aggressive disease course so that this subgroup of patients can be more efficiently managed. Our preliminary studies have suggested several candidates for further study: the papulosquamous/psoriasiform subacute cutaneous LE lesional subtype; development of acute cutaneous LE; resistance to antimalarials alone; leukopenia; high titer ANA; and the presence of circulating double-stranded DNA antibodies. Another possibility may include the rate of systemic disease onset. Discoid LE patients who have not developed clinically significant SLE manifestations within the first 2 years of the appearance of their skin lesions have a very low risk for suffering from severe SLE complications later in their disease course. The same question might be asked of subacute cutaneous LE. In addition, some subacute cutaneous LE patients have a single episode of disease activity followed by long-term, if not permanent, remission. More needs to be learned about this more benign pattern of illness in the hope of identifying favorable prognostic signs. Our impressions regarding subacute cutaneous LE disease outcome have mostly come from retrospective or point-prevalence types of clinical analyses; more prospective examinations of large groups of patients will be required to better address the issue of prognosis in subacute cutaneous LE. The data published to date suggest that this is a relatively homogeneous group of patients immunogenetically: they frequently have circulating anti-Ro auto-antibodies and often possess the HLA-DR3 phenotype. Much circumstantial evidence indicates that this particular genetically determined autoimmune response might be directly participating in pathogenesis of this form of LE-specific skin injury.(ABSTRACT TRUNCATED AT 400 WORDS)     

Electrocardiographic changes due to pyridoxine deficiency

A young woman presented with marked alterations in the ECG without cardiological symptoms or evidence of structural heart disease after further evaluation. There was evidence of vitamin deficiency and the ECG normalized after 10 days of treatment with vitamins. Similar alterations have been described in several experimental studies with rats, but this is the first case reported in humans.     

You may need the vagus nerve to understand pathophysiology and to treat diseases

Can different pathophysiological mechanisms and risk factors leading to various diseases be linked with altered transmission of signals by one common pathway? The present article provides evidence for the hypothesis that adequate vagal nerve activity reduces the risk of major diseases, via common basic mechanisms and interim risk factors. These diseases include cardiovascular disease, cancer, Alzheimer's disease and the metabolic syndrome. Three basic mechanisms contribute to such illnesses: local oxidative stress and DNA damage, inflammatory reactions and excessive sympathetic responses, all of which are inhibited by vagal nerve activity. Efferent vagal activity that can be non-invasively measured by HRV (heart rate variability), derived from an ECG, is inversely related to all three basic mechanisms, to various risk factors (e.g. diabetes and dyslipidaemia) and, more broadly, to the diseases as well. Finally, vagal activity is proposed to moderate the effects of risk factors on developing such illnesses. By proposing an integrative neurobiological model of major diseases, identifying people at risk for, and treating patients with, such diseases may be done more efficiently. People with low HRV may be identified and subsequently treated by vagus nerve activation to possibly prevent or treat such illnesses. This proposed disease paradigm may have important preventative and therapeutic implications, whose clinical effects need to be investigated.     

Highly sensitive assays of serum-thyrotropin in the diagnosis of hyperthyroidism: assessment of performance and reference values

The performance of three different highly sensitive immuno-assays for thyrotropin in serum (S-TSH) was compared. Specimens from 803 patients with suspected hyperthroidism or other thyroid disease were used. Hyperthyroid patients were identified and characterized by determining serum thyroid hormones and by clinical observation. The performance of the methods in discriminating between hyperthyroidism and euthyroidism was described in terms of diagnostic sensitivity and specificity. The performance was also assessed by systematically varying the reference values. If patients with treated hyperthroidism were eliminated, the three S-TSH assays performed equally well at a suggested lower reference value of 0.4 mU/l. A diagnostic efficiency of more than 0.95 was achieved at the observed prevalence of disease (0.12). A graphical model which allows an adjustment of reference values to favour sensitivity or specificity is presented. Reference values were also calculated from the euthyroid subjects using parametric and non-parametric approaches. The specificity, when using the recommended discrimination level, suggests that patients with low S-TSH values should be subjected to further investigation by biochemical or other methods.     

Carcinoma of the stomach disguised as a benign gastric ulcer

All gastric ulcerations must be suspected of being gastric carcinoma. Two of the more reliable signs of benignancy have been demonstration of a Hampton's line on upper gastrointestinal barium study and either roentgenographic or endoscopic evidence of ulcer healing. We have reported a case of gastric ulcer with both a Hampton's line and complete healing, which ultimately proved to be malignant.