The clinical significance of asymptomatic gross and microscopic hematuria in children

BACKGROUND: The development of asymptomatic gross or microscopic hematuria is relatively common in children. OBJECTIVE: To evaluate the clinical importance of hematuria in children and the necessity for such an evaluation using a defined diagnostic protocol. DESIGN: The protocol included a personal and family history, physical examination and blood pressure determination, and a set of comprehensive laboratory and radiological examinations. RESULTS: Of 342 children with microscopic hematuria, no cause was uncovered in 274 patients. The most common cause discovered was hypercalciuria (16%), followed by post-streptococcal glomerulonephritis (1%). Of 228 children with gross hematuria, no cause was uncovered in 86 patients. The most common cause discovered was hypercalciuria (22%). Ten patients had clinically important structural abnormalities. Fifty-three patients qualified for renal biopsy; 36 had IgA nephropathy. CONCLUSIONS: Our results suggest that diagnostic evaluation for potential causes of asymptomatic microscopic hematuria in children may not be necessary. Because microscopic hematuria can, rarely, be the first sign of occult renal disease, long-term follow-up is mandatory. As clinically important abnormalities of the urinary tract are commonly discovered in children with asymptomatic gross hematuria, a thorough diagnostic evaluation is warranted.     

The role of psychotherapy in the treatment of acute mental disorders

This work is directed to further investigate the significant relevance of psychotherapy to better management of acute psychiatric disorders. Over the last years, there was impressive increase of the amount of psychiatric patients referred to emergency and in-patient treatment and such increase all most resulted from subjects with acute emotional discontrol associated with affective, personality and stress related disorders. According to such change of the clinical scene of contemporary psychiatry, more attention and funding are needed in the field of acute treatment services and combined treatment innovation and research is become a major challenge for community psychiatry. A real progress in the field is not, however a simple matter of psychotherapy technology transference. While several recent studies suggest that well designed combined treatment is cost-effective in these patients, new nosographic, management and dynamic models are required for succesful development of new crisis intervention programs within general psychiatry services.     

Enhanced intracortical inhibition in cerebellar patients

OBJECTIVE: The aim of the study was to examine intracortical excitability in cerebellar patients. METHODS: Short-latency intracortical inhibition (SICI), long-latency intracortical inhibition (LICI) and intracortical facilitation (ICF) to paired transcranial magnetic stimulation (TMS) were investigated in 8 patients with 'pure' cerebellar syndromes and in 14 age-matched normal controls. The conditioning stimulus for short-latency intracortical inhibition and intracortical facilitation was set at 70% of the resting motor threshold (RMT) and preceded the test stimulus (110-120% of the resting motor threshold) by interstimulus intervals (ISIs) of 1-30 ms. For the long-latency intracortical inhibition determinations, the conditioning stimulus was set at 120% of the resting motor threshold and preceded the test stimulus (also 120% of the resting motor threshold) by interstimulus intervals of 30-500 ms. RESULTS: No statistically significant differences were found between patients and controls as regards either short-latency intracortical inhibition or intracortical facilitation. A significant prevalence of long-latency intracortical inhibition was present in cerebellar patients at interstimulus intervals of 200-500 ms (conditioned MEP amplitude=29-41% of test MEP) as compared to controls (71-96% of test MEP). The amplitude of conditioned MEPs was persistently less than 45% of the test MEP in six patients, who were studied at interstimulus intervals up to 1000 ms. CONCLUSIONS: Long-latency intracortical inhibition was prevalent and abnormally longer-lasting in patients. Tonic hyperactivation of a subpopulation of GABAergic interneurons in the motor cortex of patients may be the mechanism responsible for this abnormality. Our findings seem to be specific to cerebellar diseases and are the opposite of those found in movement disorders such as dystonia and Parkinson's disease. These data suggest that the cerebellum and the basal ganglia may have opposite influences in tuning the excitability of the motor cortex.     

Computed tomography evaluation of metastasis of cutaneous melanoma

PURPOSE: To assess the value of Computed Tomography (CT) in the diagnosis and in morphologic characterization of metastatic melanoma. MATERIALS AND METHODS: The data of total body CT of 124 consecutive patients with melanoma having a Breslow index 1 mm or a positive sentinel lymph node have been retrospectively reviewed. RESULTS: The CT scan showed loco-regional and/or distant metastases in 36 patients (39%). Ten of these (28%) had metastases only to lymph nodes, whereas 26 patients (72%) had multiple metastases. Nodal, pulmonary, brain, subcutaneous, hepatic, adrenal, bone, gastrointestinal, breast and abdominal wall metastases were detected in 80.6%, 47.2%, 25%, 25%, 16.7%, 13.9%, 11.1%, 5.6%, 5.6% and 2.8% of the patients respectively. All the patients with metastases also had a positive sentinel lymph nodes and/or symptoms of metastatic disease. CONCLUSIONS: CT fails to reveal any characteristic feature of metastatic melanoma, but it is of value in the diagnosis of loco-regional and distant metastases in III stage disease.     

Guidelines and clinical practice: anticoagulant therapy and cardioversion in atrial fibrillation]

The cardioversion of atrial fibrillation is linked to a substantial risk of systemic embolization. In an effort to reduce it, the American College of Chest Physicians (ACCP) periodically publishes guidelines for the use of anticoagulation in the conversion of atrial fibrillation. OBJECTIVE: Determination of the physician's compliance with the recommendations of the "Fourth ACCP Consensus Conference on Antithrombotic Therapy". METHODS: The charts of people admitted to a community hospital in 1998 with a diagnosis of atrial fibrillation (n = 202) were evaluated retrospectively. Consideration was given to the ACCP's recommendation to give anticoagulants 3 weeks before and 4 weeks after elective cardioversion to patients who had been in atrial fibrillation for more than 2 days. RESULTS: Ninety-one of the 202 patients admitted with atrial fibrillation reported the onset of arrhythmia more than 48 hours before. Thirty-four of them underwent elective cardioversion and 13 cases (33%) went without anticoagulation in the preceding 2 weeks. Of these 13 cases, 8 were patients aged over 75 (range 78-88, mean 84). After sinus rhythm had been restored in 30 people (spontaneously in 5 of them), the anticoagulant therapy was not administered during the 4 recommended weeks in 10 people (33%), all of them over 75 (range 77.94, mean 84). CONCLUSIONS: Anticoagulation for cardioversion of atrial fibrillation is underused, especially among elderly patients. In order not to let age itself be an obstacle to the correct treatment of patients with high embolic risk, our efforts must be improved in order to identify the correct therapeutic choice in each particular case. Initiatives aimed at identifying and removing any impediment to the application of guidelines may contribute to stimulating physicians in the process of evaluating the quality of hospital treatment.     

Ischemic heart disease in patients with uremia undergoing maintenance hemodialysis

The 6-year cumulative incidence of ischemic heart disease (IHD) in 382 dialysis patients (mean age [SEM], 43 +/- 0.7 years) was studied. Of 101 patients with IHD, only 39 developed symptoms following dialysis (cumulative incidence, 20.8%). This group was older than those with IHD, and in 55%, IHD occurred in the first year of dialysis. Analysis by sex and race showed the rate of IHD in men and women to be similar, but the rate in whites was twice that in blacks. In men, the rate was not different from nondialysis men with similar coronary risk factors, whereas in dialysis women, the rate was twice that of nondialysis cohort. The development of IHD did not adversely affect long-term survival in patients without prior evidence of IHD. Death from myocardial infarction occurred in 3 of 320 patients ar risk. Atuopsy data in 33 patients revealed 70% stenosis of coronary arteries in 7, 4 of whom had antecedent disease. Our major conclusions are (a) the incidence of IHD during dialysis was not different from similarly matched nondialysis subjects; (b) the rate of IHD in dialysis women was greater than it was in nondialysis subjects; (c) coronary artery disease only affected long-term survival of patients with preexisting disease; (d) autopsy data did not suggest accelerated atherosclerosis.