Outcome of knee injuries in general practice: 1-year follow-up

Background

Knee injuries may lead to pain and to functional limitations in the activities of daily living. Patients with knee injuries are frequently seen in general practice; however, the outcome and management in these patients is not known.

Aim

To assess the outcome and management of knee injuries at 12 months'' follow-up in general practice.

Design of study

A prospective observational cohort study with a 1-year follow-up.

Setting

Primary health care.

Method

Adult patients consulting their GP after knee injury (n = 134) participated in the cohort. A magnetic resonance imaging scan was carried out and patients were diagnosed as either no lesion or an isolated meniscal tear, an isolated collateral or cruciate ligament lesion, or a combination. Follow-up questionnaires were filled in up to 12 months'' follow-up.

Results

At 12 months'' follow-up, 34 patients reported full recovery and 67 patients reported major improvement. At baseline, 37 patients (28%) were referred to physical therapy and 17 patients (13%) were referred to secondary care. During 1 year of follow-up, another 21 referrals to physical therapy and 11 referrals to secondary care took place. The pain severity decreased the most, and the Lysholm knee score increased in the majority of patients during the first 3 months after injury. In total, 18 arthroscopies were performed in 15 patients. One patient underwent an anterior cruciate ligament reconstruction.

Conclusion

The vast majority of patients report clinically relevant recovery. There is no clear difference in outcomes between patients with meniscal tears or ligament lesions and patients without these diagnoses.     

Multigland Disease and Slower Decline in Intraoperative PTH Characterize Mild Primary Hyperparathyroidism

Background

Many patients with primary hyperparathyroidism (PHPT) present with less severe biochemical parameters. The purpose of this study was to compare the presentation, operative findings, and outcomes of these patients with “mild” PHPT to patients with “overt” disease.

Methods

A retrospective review of a prospectively collected parathyroid database was performed to identify cases of PHPT undergoing an initial neck operation. Patients were classified as mild when either the preoperative calcium or PTH was within the normal limits. Comparisons were made with the Student’s t test, Chi-squared test, or Wilcoxon rank-sum test where appropriate. Kaplan–Meier estimates were plotted for disease-free survival and compared by the log-rank test.

Results

Of the 1,429 patients who met inclusion criteria, 1,049 were classified as overt and 388 (27.1 %) were mild. Within the mild group, 122 (31.4 %) presented with normocalcemic PHPT and 266 (68.6 %) had a normal PTH. The two groups had similar demographics and renal function. Interestingly, the mild group had more than double the rate of kidney stones (3.1 vs. 1.3 %, p = 0.02). The mild group was less likely to localize on sestamibi scan (62.4 vs. 78.7 %, p < 0.01). Intraoperatively, more mild patients exhibited multigland disease (34.3 vs. 14.1 %, p < 0.01). When examining intraoperative PTH (IoPTH) kinetics where single adenomas were excised, the IoPTH fell at a rate of 6.9 pg/min in mild patients compared with 11.5 pg/min in the overt group (p < 0.01). Accordingly, 62.2 % of patients in the overt group and 53.3 % in the mild group were cured at 5 min postexcision (p < 0.01). There was no difference in the rates of persistence or recurrence between the groups, and disease-free survival estimates were identical (p = 0.27).

Conclusions

Patients with mild PHPT were more likely to have multigland disease and a slower decline in IoPTH, but these patients can be successfully treated with surgery.     

Decreased plasma gelsolin levels in patients with Plasmodium falciparum malaria: a consequence of hemolysis?

Mammalian plasma contains a high-affinity actin-binding protein, plasma gelsolin, that severs actin filaments. Destruction of erythrocytes could result in the release of erythrocyte cytoskeletal actin into the plasma where it could bind to gelsolin. If the clearance of actin- gelsolin complexes exceeds its synthesis, lowering of the plasma gelsolin concentration might follow. To test this hypothesis, we measured plasma gelsolin levels in patients with falciparum malaria, a disease where at least part of the hemolysis takes place in the intravascular space and that is usually not accompanied by dysfunction of other organs. Two functional gelsolin assays showed that the mean plasma gelsolin concentration of 18 Nigerian children with Plasmodium falciparum malaria was less than 50% (P less than .001) of healthy Nigerian control subjects tested at the same time. Patients with pneumonia and febrile seizures also had depressed gelsolin levels, which indicates that factors other than hemolysis can lower gelsolin concentrations. Gelsolin levels were measured in 11 patients from The Gambia with P falciparum malaria before and approximately 3 weeks after treatment. In all cases the gelsolin level increased after treatment. To confirm the hypothesis that hemolysis can result in a lowering of plasma gelsolin levels, hemolysis was induced in rabbits, either acutely (by the injection of human serum) or subacutely (by the administration of phenylhydrazine). A fall in plasma gelsolin levels was seen, the rate of fall differing with the extent of hemolysis. Affinity adsorption of plasma from animals undergoing acute hemolysis with Sepharose beads coupled to the actin-binding protein DNase I, followed by immunoblotting of adherent proteins with antiactin antiserum demonstrated the presence of actin in circulating rabbit plasma. These studies suggest that under some conditions components of the red cell cytoskeleton are exposed to plasma proteins and that accelerated clearance of actin-gelsolin complexes may explain in part the depressed plasma gelsolin levels seen in patients with falciparum malaria.     

Oral pirenzepine does not affect esophageal pressures in man

Pirenzepine has been proposed to selectively inhibit gastric acid production. In contrast to classical anticholinergics, pirenzepine does not appear to produce systemic side effects or to strongly inhibit contractions in gastrointestinal tract smooth muscle. This study compares the effects of two doses of pirenzepine (25 and 50 mgper os) with a standard anticholinergic, propantheline, 30 mgper os, and with placebo on esophageal contaction pressures in 12 healthy volunteers in a random double-blind study sequence. No significant change in lower esophageal sphincter pressure (LESP) or in peristaltic pressures occurred with placebo or pirenzepine 25 or 50 mg. However, propantheline produced marked reduction in peristaltic contraction pressures and increased velocity (4 of 12 subjects had complete loss of peristalsis). LESP decrease was almost significant. Seven of 12 subjects experienced dry mouth after propantheline, but none after either dose of pirenzepine or placebo. This study indicates that, as opposed to a classical anticholinergic, pirenzepine does not adversely esophageal contraction pressures nor does it have anticholinergic side effects with the oral doses studied.     

肝包虫囊肿的CT诊断

目的：分析了肝包虫的CT表现,讨论了CT对肝包虫的诊断价值。方法：回顾性分析35例经手术病理证实的肝包虫囊肿患者的CT表现。结果：35例肝包虫共41个包虫囊肿。单房性包虫囊肿28个,其中无钙化的16个,有钙化的6个,囊肿合并内在性破裂6个;多房性包虫囊肿13个,其中无并发症的6例,有并发症的7例;有并发症的多房性包虫囊肿中交通性破裂4个,直接破裂3个,其中5个合并细菌感染,35例患者CT术前正确诊断率为97．1％,结论：CT对各型肝包虫均有较高的诊断价值,有选择地行CT检查能为肝包虫的治疗提供更好的影像依据。     

The defective interaction between von Willebrand factor and factor VIII in a patient with type 1 von Willebrand disease is caused by substitution of Arg19 and His54 in mature von Willebrand factor

In this report we describe the further investigation of the von Willebrand factor (vWF)/FVIII interaction in a type 1 von Willebrand disease patient characterized by discrepant VIII:C levels as determined by one-stage and two-stage VIII:C assays. A solid-phase binding assay shows that this patient's plasma vWF is moderately defective in capturing recombinant FVIII. Sequence analysis of the FVIII-binding domain encoded by the vWF mRNA of the affected individual identified mutations in both vWF alleles. In allele A, the mutations C2344T and T2451A result in the substitution of Trp for Arg19 (R19W) and of G1n for His54 (H54Q) in mature vWF, respectively. This allele also contains a reported polymorphism (A2365G, Thr26Ala). Allele B, which is underexpressed at the RNA level, contains a one-nucleotide deletion in the FVIII-binding domain (delta G2515) that results in the premature termination of translation. Analysis of the binding of FVIII by full- length vWF transiently expressed in COS-7 cells confirms that the combined R19W and H54Q substitutions are the cause of the defective vWF/FVIII interaction in this patient. The FVIII-binding defect of vWF containing either mutation alone is approximately half that of the double mutant, which suggests that the effect of these mutations is additive. The mutant proteins are recognized equally well by vWF monoclonal antibodies MBC105.4, 32B12, and 31H3, which block the binding of FVIII by vWF, indicating that amino acids Arg19, Thr26, and His54 are not critical residues in the epitopes of these antibodies.     

Value of radiopaque markers in identifying partial small bowel obstruction

Confirming partial small bowel obstruction is often a diagnostic challenge. In this case report, 4-mm solid radiopaque markers were used in 4 patients to show partial small bowel obstruction. Results of enteroclysis were normal in 2 of the 4 patients, and the markers were used to challenge suspected partial obstruction. The markers coalesced in the region of the partial obstruction, which was confirmed at surgery. Enteroclysis is the examination of choice in the diagnosis of partial small bowel obstruction. However, examinations with false- negative results can occur, particularly with adhesive and/or intermittent obstructions. The use of radiopaque markers in these cases proved an effective and useful method of establishing the diagnosis of partial small bowel obstruction, particularly in the 2 cases in which enteroclysis results were normal. Prospective studies are needed to establish the feasibility of this novel technique. (Gastroenterology 1996 Jun;110(6):1958-63)