Budd chiari syndrome and coarctation of inferior vena cava

Budd Chiari Syndrome encompasses several aetiological factors. Coarctation of inferior vena cava is characterised by an hour glass constriction of the cava with or without occlusion of the terminal hepatic veins. The latter may be occluded with minimal or no changes in the interior vena cava. This entity has been reported worldwide, but commonly from Africa, China, India and Japan. Characteristic findings on ultrasonography, and functional hepatography are illustrated. Surgical procedures for caval decompression (including operative features in authors’ series of 24 patients), portal decompression, hepatic venous decompression, and relief of ascites are outlined. Arguments for or against congenital hypothesis, primary thrombotic theory, or primary inflammatory cause are listed. The possibility of filarial aetiology is discussed. Based on the Hunterian Lecture Delivered by Professor Solomon Victor at the Royal College of Surgeons of England, London, in 1991     

Transcranial Doppler detection of anterior cerebral artery vasospasm.

The performance of transcranial Doppler in the detection of anterior cerebral artery vasospasm and vasospasm in patients after subarachnoid haemorrhage was analysed. Transcranial Doppler and cerebral angiography were performed within the same 24 hours on each of 41 patients with acute subarachnoid haemorrhage. Sensitivity and specificity of transcranial Doppler to classify middle cerebral arteries, anterior cerebral arteries, and patients with angiographic vasospasm were determined at mean velocities of 120 and 140 cm/s. Accuracy of transcranial Doppler was better at 140 than at 120 cm/s. For the middle cerebral artery, sensitivity was 86%, specificity 98%. For the anterior cerebral artery, sensitivity was 13%, specificity 100%. Among all patients, sensitivity was 45%, specificity 96%. Among patients with anterior communicating artery aneurysms, sensitivity was 14%, specificity 90%. Therefore, transcranial Doppler accurately differentiates between middle cerebral arteries with and without vasospasm on angiography, but has a very low sensitivity for detecting anterior cerebral artery vasospasm and vasospasm in patients with anterior communicating artery aneurysms. Since vasospasm may involve anterior cerebral arteries while sparing middle cerebral arteries, especially after rupture of an anterior communicating artery aneurysm, caution should be exercised in using negative transcranial Doppler results to make treatment decisions based on the assumed absence of vasospasm.     

A randomized controlled trial of mailed osteoporosis education to older adults

Introduction Osteoporosis represents a growing public health concern; however, current rates of management are sub-optimal. The aim of our study was to assess, in a randomized controlled trial, the effect of a mailed educational intervention on older adults’ knowledge, attitudes, and preventive behaviors regarding osteoporosis. The setting was a large publicly funded state pharmacy benefits program. The patients were 31,715 Medicare beneficiaries from Pennsylvania who participated in a drug benefits program for low-to-moderate income elderly people. Methods All women aged over 65 years, and all men and women with a history of fracture or long-term oral use of glucocorticoid, were included. Approximately half of the participants (intervention group) were randomly selected to receive three mailings aimed at improving knowledge of osteoporosis and enhancing preventive activities, such as using calcium and vitamin D, reducing fall risks in the home, obtaining a bone mineral density (BMD) test, and taking medications when necessary. The other participants did not receive the intervention mailings and served as controls. We surveyed a sample of intervention and control subjects to determine the effects of the intervention on knowledge, attitudes, self-efficacy (confidence in one’s ability to perform specific activities), and behavior regarding osteoporosis prevention and treatment. Six hundred randomly selected participants in the intervention group and an equal number in the control group were invited to participate. Results Twenty-six had died and 636 of the remaining 1,185 (54%) completed the survey. Respondents and non-respondents did not differ significantly with respect to measured sociodemographic factors. All scales had good reliability (all Cronbach’s alphas >0.65). Knowledge of osteoporosis was generally very good and did not differ between intervention (mean = 65% correct responses) and control subjects (mean = 67% correct; P=0.4). Perceived susceptibility to osteoporosis was relatively high and similar across groups (P=0.4). Self-efficacy for participating in osteoporosis prevention and treatment was very strong in both the intervention (mean = 4.3 on a 0–5 scale) and control (mean = 4.2, P=0.03) groups . On average, subjects in the intervention group reported participating in 3.5 of 6 preventive osteoporosis activities compared with 3.4 in the control group (P=0.5). Conclusions Compared with the controls, a mailed educational intervention for osteoporosis was not associated with better knowledge, higher perceived susceptibility, or performance of preventive measures among the at-risk older adults that we studied. The intervention group demonstrated a small increase in self-efficacy. More intensive patient interventions or intervention aimed at other aspects of the care process may be required to bring about changes that lead to a reduction in fractures.     

Infection with the human immunodeficiency virus: clinical manifestations and their relationship to immune deficiency. A report from the Multicenter AIDS Cohort Study

In 1984 a large prospective study of gay and bisexual men was begun to elucidate the natural history of the human immunodeficiency virus (HIV) infection. At two successive semiannual examinations, clinical or hematologic abnormalities were found up to 13 times more often among HIV-seropositive men (n = 1611) than HIV-seronegative men (n = 2646). More than 30% of the seropositive participants had persistent generalized lymphadenopathy, independent of T-helper lymphocyte (CD4) counts and most other signs and symptoms. Other clinical manifestations such as thrush, anemia, thrombocytopenia, neutropenia, fever, and fatigue occurred with only slightly reduced CD4 counts (400 to 700/mm3) and appeared to increase exponentially with progressively lower counts. A simple systematically derived clinical index using these manifestations identified more than 70% of the seropositive men with significant T-helper cell depletion. This kind of clinical index may be useful for assessing groups of HIV-infected persons, especially those whose T-lymphocyte numbers and function cannot be readily measured.     

Headache in HIV-1-Related Disorders

To define the causes, clinical significance and characteristics of headaches in HIV-1-related disorders, we studied 49 consecutive HIV-1 infected patients who presented with headache. Work-up included CT scans, cerebrospinal fluid examinations (in the absence of a contraindication) and serologic studies. Overall, 40 of 49 patients (82 percent) had an identifiable serious cause of headache. Cryptococcal meningitis (39 percent) and CNS toxoplasmosis (16 percent) were the leading headache etiologies. Serious causes were more likely in patients diagnosed with AIDS prior to presentation but also occurred in most patients in early stages of infection. Based on this study, we suggest that patients with HIV-1 infection must be managed with a high index of suspicion when they present with new onset headaches.     

An approach to the human immunodeficiency virus-positive patient with a spondyloarthropathic disease

One of the unanticipated consequences of infection with the human immunodeficiency virus (HIV) is the appearance of various rheumatic syndromes that traditionally have been thought to result from inappropriate overactivity of the immune system. This distinctive spectrum of rheumatic syndromes has been well described; however, the therapeutics and specific patient management as well as the significance of these disorders for diagnostic classification of the rheumatic disorders have not received a great degree of attention. This article focuses on these areas with emphasis on (1) the nosology of the arthrocutaneous musculoskeletal syndromes with HIV, (2) clinical presentation of the various syndromes, (3) current concepts regarding the etiopathogenesis of the spondyloarthropathic form of arthritis in this setting, and (4) an approach to therapy.     

Antiulcer agents. 3. Structure-activity-toxicity relationships of substituted imidazo[1,2-a]pyridines and a related imidazo[1,2-a]pyrazine

Investigation of the interrelationship between structure, antiulcer activity, and toxicology screening data derived from a series of compounds selected from structure-activity studies directed toward identifying a successor to 3-(cyanomethyl)-2-methyl-8-(phenylmethoxy)imidazo[1,2-a]pyridine, Sch 28080 (1), has identified 3-(cyanomethyl)-2,7-dimethyl-8-(phenylmethoxy)imidazo[1,2 -a]pyridine (5), 3-amino-2-methyl-8-(2-phenylethyl)imidazo[1,2-a]pyridine (6), and 3-amino-2-methyl-8-(phenylmethoxy)imidazo[1,2-a]pyrazine (7). These analogues exhibit a combination of antisecretory and cytoprotective activity in animal models, while eliminating the adverse effects of the prototype 1. One of these, 3-amino-2-methyl-8-(phenylmethoxy)imidazo[1,2-a]pyrazine, Sch 32651 (7), has a profile meeting all criteria.     

Evaluation and implementation of public health registries

A rapid proliferation of registries has occurred during the last 20 years. Given the long-term commitment of resources associated with registries and limited public health funding, proposals for new registries should be carefully considered before being funded. A registry is defined as a data base of identifiable persons containing a clearly defined set of health and demographic data collected for a specific public health purpose. Criteria for evaluating whether a registry is needed, feasible, or the most effective and efficient means of collecting a specific set of health data are presented. They include an evaluation of the stated purpose; a review of the function, duration, and scope of the registry; consideration of existing alternative data sources; an assessment of the practical feasibility of the registry; the likelihood of sufficient start-up and long-term funding; and an evaluation of the cost effectiveness of the registry. Creating a public health registry is a complex process. A range of technical and organizational skills is required for a registry to be successfully implemented. Eight requirements are identified as crucial for the successful development of a new registry. They include an implementation plan, adequate documentation, quality control procedures, case definition and case-finding (ascertainment) procedures, determination of data elements, data collection and processing procedures, data access policy, and a framework for dissemination of registry data and findings.     

Usefulness of ovarian volume and cysts in female isosexual precocious puberty

The real-time pelvic sonograms of 32 girls under 8 years old with true isosexual precocity (23 cases), pseudosexual precocity (four cases), premature adrenarche (four cases), and an undetermined problem (one case) were evaluated retrospectively for ovarian volume and presence and size of cysts. Sonographic findings were compared to those of 181 age-matched controls to determine the best sonographic indicator of precocious puberty. Ovarian volume was 4.6 cm3 in girls with true isosexual precocity, 4.1 cm3 in girls with pseudosexual precocity, and less than 1 cm3 in the other patients as well as in the control population. Ovarian enlargement was bilateral in true precocity and unilateral in pseudosexual precocity. Of the 181 subjects in the control group, 96 (53%) had ovarian cysts, almost all of which were small (less than 9 mm in diameter). Ovarian cysts occurred in 22 of 32 patients (69%) with precocity. The cysts generally were smaller than 9 mm in true isosexual precocity and larger than 9 mm in pseudosexual precocity. In conclusion, small ovarian cysts are not specific to precocious puberty and its various subtypes. Bilateral ovarian enlargement appears to be a reliable indicator of true isosexual puberty, whereas unilateral ovarian enlargement in combination with macrocysts is suggestive of pseudosexual precocity.