Diagnostic utility of computer tomographic enterography for patients presenting with unexplained gastrointestinal symptoms

Background/Aims: Computer tomographic enterography (CTE) is gaining approval for evaluation of small bowel diseases. However, the diagnostic yields of CTE for diseases other than Crohn's disease have not yet been well elucidated. The aim of the present study was to determine the diagnostic utility of CTE and to ascertain the clinical factors predictive of the positive diagnostic rate in patients with unexplained gastrointestinal symptoms or signs. Methodology: The clinical and radiological data of 193 patients with unexplained gastrointestinal symptoms that had a CTE examination at Severance Hospital between May 2007 and April 2010 were retrospectively analyzed. Results: CTE revealed positive findings that explained the symptoms in 51 of the 193 patients (diagnostic yield 26.4%). Positive findings of diagnosis included cancer (12 patients), Crohn's disease (10), intestinal stricture/obstruction (9), small bowel bleeding (7), colitis (6), intestinal Behcet's disease (4), intestinal tuberculosis (2) and intestinal fistula (1). According to univariate analysis, the positive findings of CTE were significantly associated with higher segmentated neutrophil count (p<0.001), higher erythrocyte sedimentation rate (ESR) (p=0.003), higher C-reactive protein (CRP) level (p=0.008) and lower serum albumin level (p=0.037). Multivariate analysis indicated that elevated CRP level was a significant risk factor for the positive findings of CTE (odds ratio 1.950; 95% CI (1.165-3.265), p=0.011). Conclusions: The results of this study suggest that CTE could be helpful in patients suffering from unexplained gastrointestinal symptoms that cannot be explained by established examinations, especially those with elevated C-reactive protein levels.     

Dry eyes and mouth syndrome--a subgroup of patients presenting with sicca symptoms

OBJECTIVE: To evaluate the characteristics of patients presenting with symptoms suggestive of Sj?gren's syndrome (SS) but failing to satisfy diagnostic criteria. METHODS: Clinical, serological and histological data were collected on 34 patients presenting with dry eyes and/or mouth who did not satisfy the Vitali criteria for the diagnosis of SS. They were compared with 136 patients with primary SS, 38 patients with secondary SS, and 13 patients without SS. Questionnaires on symptoms from each group were compared with 43 healthy controls. RESULTS: The 34 patients who did not satisfy the diagnostic criteria for SS or any other connective tissue disease were designated dry eyes and mouth syndrome (DEMS). Their demography including age was similar to that of a primary SS group and there was no more atrophy seen on their biopsies compared with SS and non-SS controls. They scored highly on visual analogue scales of symptoms but had few objective signs. All were negative for anti-Ro and anti-La although the prevalence of antinuclear antibodies (19%) was increased compared with a normal population. There was no excess of SS-associated tissue types. CONCLUSION: There was no evidence that age, salivary gland atrophy or subclinical SS accounted for the symptoms in DEMS. Most of the patients fitted into a spectrum of disease which tended more towards fibromyalgia and/or chronic fatigue syndrome.     

神经系统症状为主的房间隔缺损患者的特征及疗效分析

目的探讨以右向左分流致神经系统症状为临床表现的房间隔缺损患者的临床特征及封堵疗效。 方法纳入2019年1月至2021年10月在南京医科大学第一附属医院神经内科就诊主诉为偏头痛或卒中相关症状的房间隔缺损患者,且由经颅多普勒超声发泡试验（c-TCD）证实存在右向左分流,收集其基本信息、c-TCD、经胸超声心动图（TTE）、经食管超声心动图（TEE）、右心导管检查结果,分析患者临床特征。术后随访0.5～1.5年,偏头痛患者完善头痛影响测定量表（HIT-6）评分及偏头痛失能程度评估问卷（MIDAS评分）,评估封堵疗效。 结果研究共纳入14例患者,年龄（55.8±12.4）岁,其中女9例（57.1％,9/14）。偏头痛6例,脑卒中8例,TTE及右心导管检查提示无右心代偿性增大,肺血管阻力<3 Wood,评估不存在右心容量超负荷。14例患者均行经皮房间隔缺损封堵术。与术前相比,6例偏头痛患者术后HIT-6及MIDAS评分均明显降低（P=0.024;P=0.027）。8例缺血性卒中患者均无脑卒中复发。 结论成人房间隔缺损而无右心容量负荷升高者首发症状可以表现为神经系统症状,且c-TCD检查可为阳性。介入封堵治疗可有效缓解症状。     

The association between naltrexone treatment and symptoms of depression in opioid-dependent patients

Objective: To examine the change in total symptoms, and symptom clusters, of depression in newly abstinent opioid-dependent individuals being treated with depot naltrexone (Depotrex; Biotek, Inc., Wellesley, MA). Method: In a series of opioid-dependent patients (N = 34) treated with naltrexone maintenance and relapse prevention therapy, mood was assessed with a 17-item Hamilton Depression (HAM-D) Scale and subscale scores at baseline, and after naltrexone induction at 2- and 4-week post-baseline. Data were analyzed using generalized estimated equation (GEE) models. Results: Patients demonstrated high baseline affective burden and significant improvement of depression scores over a 4-week period post-baseline (F_2.66 = 8.88; p = .0004). Somatic and cognitive-affective subscale scores significantly declined as well as the seven individual item scores. By contrast, the “late insomnia” item score significantly increased at 2 weeks post-baseline. Conclusions and Scientific Significance: Naltrexone induction and maintenance in newly abstinent opioid-dependent individuals does not appear to be associated with worsening of depression; however, it may be associated with sleep impairment early in treatment.     

Hypothyroidism with presenting symptoms of fibrositis

Eight patients who initially presented with signs and symptoms of the fibrositis syndrome, without overt hypothyroid disease, were found to have chemical evidence of hypothyroidism. Myalgic symptoms resolved in 6 of 8 patients treated with low dose thyroid replacement. In addition, another hypothesis of pathophysiology of the myalgic symptoms observed in patients with hypothyroidism related to sleep disturbance is offered.     

Sexual behaviour,STDs and drug use in a crack house population

We aimed to investigate the prevalence of ulcerative sexually transmissible diseases (STDs) and hepatitis in crack users. We interviewed 435 crack users on site in crack houses in Houston, Texas and took blood for laboratory analysis. There was evidence of syphilis infection in 13%, herpes simplex virus-2 (HSV-2) in 61%, HIV in 12%, hepatitis B in 52%, and hepatitis C in 41% of cases. On DSM-III-R criteria, 12% were crack abusers and 84% crack dependent: over half reported previous treatment. Forty per cent reported also injecting. Sexual behaviour indicated a mean of 2.4 partners in the past month for men, 3.7 for women. Sexual behaviour was largely vaginal, although women also reported more than twice the level of oral sex of men. Significant multivariate predictors for HIV and hepatitis B and C were previous reported STD and injecting drug use (including sharing needles), while female gender for syphilis and HSV-2, and additionally condom use for HSV-2, were significant risks. These data confirm high rates of STDs in a crack house population as inferred from previous clinic-based and community studies, and the link between STDs, injecting and HIV. The high rates of STDs found should lead to considering STDs and substance abuse to be dual diagnoses in crack users and the integration of STD diagnosis and treatment into crack outreach and treatment programmes.     

Differences in trigger factors and symptoms between patients with asthma-like symptoms and patients with asthma: development of a basis for a questionnaire

Patients with asthma-like symptoms but with negative asthmatests are often misdiagnosed as having asthma and treated as asthmatics.They describe their trigger factors and symptoms very similar to those of patients with asthma. The aim of the study was to analyze differences in symptoms and trigger factors between asthma-like patients and asthmatics in order to elaborate a basis for a questionnaire for epidemiological and clinical use. A questionnaire with 54 questions about trigger factors and 137 questions about symptoms was sent to 40 patients with asthma-like symptoms and 40 with asthma, all consecutively selected from patients referred to an out-patient clinic for asthma and allergy for investigation of suspected asthma. Data were analyzed statistically in two steps using multiple logistic regression analysis. Significant differences were seen in several trigger factors and symptoms after the first analysis. After the second analysis, seven out of the 54 trigger factors and 22 out of the 137 symptoms emerged as those that most significantly discriminated between the two patient groups. These trigger factors and symptoms can be the basis of a new questionnaire with high discriminating power. Before using it, it is important to evaluate the best combination of variables, add some demographic variables and totestthe reliability and validity ofthis new questionnaire.     

Behaviors That Facilite Sexual Transmission of HIV and STDs in a Rural Community

We studied sexual disease transmission behaviors among patients of a county sexually transmitted disease (STD) clinic in rural North Carolina. Six hundred-sixty patients responded to a 147-item questionnaire. Among those with symptoms (N = 358), 50% of the men and 66% of the women came to the clinic a week or more after experiencing symptoms of a curable infection. Sixty-eight percent of the men and 39% of the women reported having multiple sex partners in the last 3 months. Fifty-nine percent of men and women reported never using a condom during vaginal sex with their main partner. Condom non-use was twice as likely with main partners than with casual ones. Factors independently associated with condom non-use (older age, cohabitation, non–African-American race, and social norms for risky sex) did not vary by partner type after the correlational nature of these data was taken into account. STD-related behaviors among STD clinic clients in this rural county were at least as frequent as reported for urban populations. The relative absence of anonymity in a small community may play a role in several of the behaviors.     

Three patients with isolated adrenocorticotropin deficiency presenting with neuroleptic malignant syndrome-like symptoms.

We report 3 patients with isolated adrenocorticotropin (ACTH) deficiency presenting with neuroleptic malignant syndrome (NMS)-like symptoms. All patients were in their 60's or 70's and showed consciousness disturbance, a high-grade fever, extrapyramydal signs, and muscle enzyme elevations, which met the criteria for NMS. Also, they all showed hyponatremia induced by isolated ACTH deficiency. In addition to the standard therapy for NMS, corticosteroid supplement therapy was effective in all patients. There thus appear to be subjects with isolated ACTH deficiency among patients presenting with NMS-like symptoms, and adrenal and pituitary function should be checked in NMS patients with hyponatremia.     

Cocaine-related symptoms in patients presenting to an urban emergency department

STUDY OBJECTIVES: Cocaine abuse is a serious social problem that precipitates a significant number of emergency hospital encounters. To determine the nature of cocaine-related symptoms, we studied patients with cocaine use presenting to all adult services of an urban emergency department. DESIGN: Review of consecutive cases, with analysis of clinical features. SETTING: All adult EDs of an urban teaching hospital. TYPE OF PARTICIPANTS: Patients acknowledging recent use of cocaine (within 72 hours) and/or with cocaine detected on a toxicologic screen. MEASUREMENTS AND MAIN RESULTS: Psychiatric complaints accounted for 44 (30.6%) presentations, followed by neurologic (17.4%), cardiopulmonary (16%), trauma (11.8%), and addiction-related (11.1%) symptoms. Cardiopulmonary symptoms were more frequently associated with intranasal than with IV or smoked cocaine (P = .003). Suicidal intent was the most common psychiatric reason for presentation, occurring in 24 patients (16.6%). Seventeen presented with trauma, including three involved in motor vehicle accidents. CONCLUSION: Cardiopulmonary symptoms such as chest pain and palpitations may be significantly more frequent in patients who use intranasal cocaine; suicidal intent is common among patients presenting with psychiatric symptoms related to cocaine; and the range of cocaine-related symptoms is varied, including not only psychiatric and cardiopulmonary symptoms but also trauma.     

Tobramycin in patients with cystic fibrosis. Adjustment in dosing interval for effective treatment

The efficacy of the dosing regimen of tobramycin was investigated in 28 patients with cystic fibrosis who had an acute exacerbation of chronic pulmonary infection with Pseudomonas aeruginosa. The initial dose of tobramycin was 3.3 mg/kg of body weight three times daily (ie, 10 mg/kg/day). A highly significant relationship was found between the serum concentration of tobramycin before the dose and the change in the forced expiratory volume in one second (FEV1), both measured on the tenth day of treatment (rs = 0.75; p less than 0.001). In nine of the 16 patients who had a six-hour serum concentration of 1 mg/L or less on the tenth day of treatment, the eight-hour dosing interval of tobramycin was shortened to achieve a serum concentration of tobramycin of about 1 mg/L before the dose. In the other seven patients, the dosage of tobramycin was not changed. On the 20th day, seven of the nine patients in whom the dosing interval was shortened exhibited an increase in FEV1 of 20 percent or more. Such an increase was observed only in one of the seven patients in whom the dosing interval was not reduced (p less than 0.05). We conclude that individualizing the dosage of tobramycin in patients with cystic fibrosis results in a better clinical outcome.     

Analysis of the acidity index and integrated intragastric acidity in 645 patients presenting with gastroesophageal reflux disease symptoms

OBJECTIVE: In a recent study of patients receiving proton-pump inhibitor (PPI) therapy, a new parameter, the acidity index, was described as being less complicated to calculate and of comparable accuracy (r = 0.93) to integrated intragastric acidity (IA) in assessing intragastric pH control. The aim of this study was to correlate AI with IA using a large database of ambulatory 24-h pH-metry studies in untreated patients presenting with gastroesophageal reflux disease (GERD) symptoms. MATERIAL AND METHODS: We retrospectively analyzed 645 studies obtained from 1995 to 2001. Daytime (0800 h-2200 h), night-time (2200 h-0800 h) and 24-h IA and AI were calculated according to age, gender and the presence or absence of GERD, and correlations between these parameters were assessed using linear regression with F-statistic values, p-values and Akaike's Information Criterion values. GERD was defined as total esophageal pH time <4.0, 5 cm above the lower esophageal sphincter, for > or =4.2% of the day. IA and AI were calculated as follows: IA (mmol x h/l) = summation operator(acid in mmol/l at time "t" + acid in mmol/l at time "t - 1")/2 x ("t"-"t - 1"); AI = (%time pH < 4-%time pH < 3) x 1+(%time pH < 3-%time pH < 2) x 10+(%time pH < 2-%time pH < 1) x 100 + (%time pH < 1-%time pH < 0.8) x 1000. RESULTS: Overall, the mean 24-h IA value was 882.0+/-820.0 mmol x h/l (daytime 392.0+/-400.0, night-time 490.0+/-486.0). The mean 24-h AI value was 102.0+/-87.0 (daytime 86.0+/-80.0, night-time 120.0+/-114.0, p < 0.001). The mean 24-h IA value was 1057.0+/-829.4 mmol x h/l (daytime 459.8+/-406.0, night-time 597.2+/-500.4, p < 0.001) in GERD patients and 713.0+/-775.0 mmol x h/l (daytime 326.0+/-383.0, night-time 387.0+/-448.5) in non-GERD patients (p < 0.001). The mean 24-h AI value was 122.1+/-88.1 (daytime 101.4+/-82.5, night-time 145.3+/-120.7) in GERD patients and 83.0+/-81.0 (daytime 71.0+/-73.9, night-time 96.4+/-102.6) in non-GERD patients (p < 0.001). Our statistical modeling demonstrated that the correlation between the acidity index and IA becomes progressively poorer with increasing values of acidity. CONCLUSIONS: We conclude that gastric acid production assessed by both IA and AI is higher during evening hours in comparison with daytime hours and the difference between night-time and daytime values is statistically significant. In addition, gastric acid production assessed by both IA and AI is significantly higher in GERD patients than non-GERD patients. This difference is primarily due to differences in nocturnal acid production. The AI correlates poorly with measured IA, especially at higher levels of gastric acidity. Therefore, AI is not an acceptable surrogate for IA in assessing gastric acid production.     

Analysis of the acidity index and integrated intragastric acidity in 645 patients presenting with gastroesophageal reflux disease symptoms

Objective. In a recent study of patients receiving proton-pump inhibitor (PPI) therapy, a new parameter, the acidity index, was described as being less complicated to calculate and of comparable accuracy (r=0.93) to integrated intragastric acidity (IA) in assessing intragastric pH control. The aim of this study was to correlate AI with IA using a large database of ambulatory 24-h pH-metry studies in untreated patients presenting with gastroesophageal reflux disease (GERD) symptoms. Material and methods. We retrospectively analyzed 645 studies obtained from 1995 to 2001. Daytime (0800?h–2200?h), night-time (2200?h–0800?h) and 24-h IA and AI were calculated according to age, gender and the presence or absence of GERD, and correlations between these parameters were assessed using linear regression with F-statistic values, p-values and Akaike's Information Criterion values. GERD was defined as total esophageal pH time <4.0, 5?cm above the lower esophageal sphincter, for ≥4.2% of the day. IA and AI were calculated as follows: IA (mmol.h/l)?=?∑(acid in mmol/l at time “t”?+?acid in mmol/l at time “t???1”)/2×(“t”–“t???1”); AI=(%time pH?Results. Overall, the mean 24-h IA value was 882.0±820.0?mmol.h/l (daytime 392.0±400.0, night-time 490.0±486.0). The mean 24-h AI value was 102.0±87.0 (daytime 86.0±80.0, night-time 120.0±114.0, p<0.001). The mean 24-h IA value was 1057.0±829.4?mmol.h/l (daytime 459.8±406.0, night-time 597.2±500.4, p<0.001) in GERD patients and 713.0±775.0?mmol.h/l (daytime 326.0±383.0, night-time 387.0±448.5) in non-GERD patients (p<0.001). The mean 24-h AI value was 122.1±88.1 (daytime 101.4±82.5, night-time 145.3±120.7) in GERD patients and 83.0±81.0 (daytime 71.0±73.9, night-time 96.4±102.6) in non-GERD patients (p<0.001). Our statistical modeling demonstrated that the correlation between the acidity index and IA becomes progressively poorer with increasing values of acidity. Conclusions. We conclude that gastric acid production assessed by both IA and AI is higher during evening hours in comparison with daytime hours and the difference between night-time and daytime values is statistically significant. In addition, gastric acid production assessed by both IA and AI is significantly higher in GERD patients than non-GERD patients. This difference is primarily due to differences in nocturnal acid production. The AI correlates poorly with measured IA, especially at higher levels of gastric acidity. Therefore, AI is not an acceptable surrogate for IA in assessing gastric acid production.     

Analysis of the colonoscopic findings in patients with rectal bleeding according to the pattern of their presenting symptoms

Patients presenting with rectal bleeding were prospectively categorized according to the pattern of their presentation into those with outlet bleeding (n=115), suspicious bleeding (n=59), hemorrhage (n=27), and occult bleeding (n=68). All patients underwent colonoscopy and this was complete in 94 percent. There were 34 patients with carcinoma and 69 with adenomas >1 cm diameter. The percentage of neoplasms proximal to the splenic flexure was 1 percent in outlet bleeding, 24 percent with suspicious bleeding, 75 percent with hemorrhage, and 73 percent with occult bleeding. Barium enema was available in 78 patients and was falsely positive for neoplasms in 21 percent and falsely negative in 45 percent. Colonoscopy is the investigation of choice in patients with suspicious, occult, or severe rectal bleeding. Bleeding of a typical outlet pattern may be investigated by flexible sigmoidoscopy.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Toronto, Canada, June 11–16, 1989.