SYSTEMIC LUPUS ERYTHEMATOSUS—Early Cytologic Diagnosis

The diagnosis of systemic lupus erythematosus—a relatively common disease—is difficult because of the variable nature of the symptoms, which resemble those of many other conditions. The finding of the characteristic cells is pathognomonic, although failure to find them does not rule out the diagnosis.If the diagnosis is suspected the “L.E.” cell test should be performed on two samples of blood from the veins and one from the bone marrow. After separation of a haparinized sample by centrifuge, a drop from the buffy coat is Wright-stained on a slide and examined for rouleaux formation and for a hematoxylinstaining material sometimes seen in intercellular bodies (which may be surrounded by a rosette of leukocytes) and sometimes seen as ingested by a leukocyte. Only the last finding is positively diagnostic of lupus erythematosus.A statistical analysis of 62 cases treated at the Los Angeles County General Hospital is given. Because of the frequency of rheumatoidlike arthritic changes in the disease, all patients with this form of arthritis should be given the test. Spontaneous remission and then relapse after a long asymptomatic interval occurred in many cases. With early diagnosis and vigorous treatment with cortisone and corticotropin, many patients can be relieved of symptoms.     

Botulism—Diagnosis,Management and Public Health Considerations

Botulism is an uncommon but often fatal disease associated with ingestion of a potent neurotoxin present in improperly preserved foods. Exposures to commercially preserved foods with an odd or peculiar taste almost never represent exposure to botulism toxin. Improperly prepared home-canned products which are tasted or consumed without heating are more likely to be associated with botulism.The management of suspect and confirmed cases of botulism is presented by medical epidemiologists in the State Department of Public Health, Bureau of Communicable Disease Control, to provide physicians in California with a practical approach to this problem.     

CARCINOMA OF THE THORACIC ESOPHAGUS—A Discussion of Early Diagnosis and Surgical Treatment

Dysphagia, substernal or epigastric distress, and regurgitation of food are important early symptoms in the diagnosis of carcinoma of the esophagus. Temporary remission in symptoms does not rule out esophageal cancer. The use of thick barium meal and routine thorough examination of the esophagus in upright and supine positions in all upper gastrointestinal roentgen studies, even though the clinical symptoms point to the upper abdomen, are of great importance.The spread of the cancer to both mediastinal and subdiaphragmatic lymph nodes makes transthoracic thoracolaparotomy the one approach which will permit the surgeon to perform a one-stage esophagogastrostomy, and to adequately evaluate and deal with cancerous tissue on both sides of the diaphragm. This one-stage procedure permits the patient to swallow normally after operation, and the costly and time-consuming uncertainties of the many-staged operations are avoided. The comfort which the operation gives to otherwise doomed patients, along with the improving postoperative mortality rate, offers new hope to those who have cancer of the esophagus.     

WHIPLASH INJURIES—Diagnosis and Treatment

Whiplash injury may extend far beyond the neck, and may involve even the soft tissues of the pelvis. For permanent recovery, all the injuries must be evaluated and treated together.When impact from the rear snaps the head back and then forward, posterior subluxations in the cervical spine cause anterior-posterior narrowing of the intervertebral foramina, which may result in injury to the cervical nerve roots. Impact at the front, causing hyperflexion followed by hyperextension, has a similar effect although usually not as severe. Resulting symptoms may not appear until two or three weeks later, when irritative lesions have developed because of hemorrhage or swelling. Mild or progressive degenerative changes may cause no symptoms but may predispose the affected area to injury following some slight trauma. Capsular ligaments of the lateral intervertebral joints are especially liable to whiplash injury which may give rise to scars and adhesions that compress spinal nerves. Sympathetic system involvement may cause reflex and referred pain.Detailed neurologic, roentgen and electromyographic studies may be necessary for proper evaluation of injuries. Seemingly psychosomatic pain or disability is likely to have some physical basis in whiplash injuries.In 33 patients with whiplash injury, some recently injured and some chronically disabled with persistent symptoms, good results were observed following hydromassage, hot packs, joint mobilization exercises and, in a few, cervical or pelvic traction.     

MALFUNCTIONING POSTGASTRECTOMY STOMA—Diagnosis and Treatment

Individualization in the treatment of patients with malfunctioning gastrojejunostomy stomas is paramount. Prompt surgical intervention in critically ill patients is necessary to save life.In the early postoperative phase, the use of barium studies is disappointing and very seldom gives information as to the actual site of the obstruction.In surgical treatment, operation directly upon the stoma should be avoided as much as possible. The release of small bowel obstruction, the reduction of intussusception or the correction of retraction of the jejunum through the mesocolon can be accomplished readily. Double or single jejunostomy for feeding and decompression are all that is necessary in cases in which no cause can be found for obstruction at or below the stoma.In a patient with peptic ulcer, the use of enteroenterostomy below the stoma is unphysiological and will predispose to gastrojejunal ulcer at a later date.     

Upper Gastrointestinal Hemorrhage—Diagnosis and Management

The current management of a patient with upper gastrointestinal hemorrhage involves three steps: initial correction of unstable hemodynamics, obtaining the specific diagnosis of the lesion responsible for gastrointestinal blood loss, and therapy directed at the specific bleeding lesion. The current approach to upper gastrointestinal hemorrhage is carrying out upper gastrointestinal endoscopy following stabilization of the patient. Although improved morbidity and mortality statistics have been slow to appear, the use of endoscopy permits appropriate therapy directed at the specific lesion. Specific therapeutic measures have been outlined for seven common causes of upper gastrointestinal hemorrhage. The advent of therapeutic endoscopy promises to bring further advances in therapy in the near future.     

NONALLERGIC ASTHMA—Differential Diagnosis and Treatment

A classification of asthma into allergic and nonallergic has gained support from the more recent studies on the underlying causes of the disease.The majority of instances of nonallergic asthma occur after middle life and result from recurrent infections of the upper and lower respiratory tract. Status asthmaticus is a frequent complication of infectious asthma.Chronic and intractable asthma may be present also in a patient with allergic asthma complicated by a superimposed infection of the sinuses, bronchi and lungs.There are many secondary or precipitating causes that may bring on asthmatic paroxysms. The most important of these are acute respiratory infections, mechanical and chemical irritants, autonomic imbalance, hormonal deficiencies and psychogenic influences. These secondary causes play a more important role in nonallergic asthma because of the greater tendency to chronicity in this form of the disease.The effective treatment of chronic asthma depends largely on the successful control of the secondary or precipitating causes of the asthmatic attacks.The introduction of the antibiotics and corticosteroids in the treatment of infectious asthma has supplied potent weapons to combat the disease. The use of these therapeutic agents makes possible the control of two of the important pathologic lesions of asthma—bronchial infection and bronchial inflammation.At present combined antibiotic and cortisone or hydrocortisone therapy of asthma seems to be the most rational method of preventing the disease from becoming chronic and intractable. Their value in infectious asthma is due to their anti-infective and antiflammatory action.When prolonged treatment is essential, combined therapy also lessens the dangers arising from the presence of masked infections.     

DRUGS IN PREGNANCY—Their Effects on the Fetus and Newborn

In considering drug therapy for pregnant women, it must be borne in mind that almost all chemical compounds in use as therapeutic agents pass from the maternal to the fetal circulation through the placenta. These drugs can produce a wide range of harmful effects on the fetus and neonatal infant. The effects of some substances for which we have data reflecting a deleterious effect are listed.It is suggested that in the future more caution be exercised in using drugs during pregnancy and that in histories, both obstetrical and pediatric, any therapy given to the mother during gestation be recorded in detail.     

American Association of Clinical Endocrinologists and American College of Endocrinology Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis — 2016--Executive Summary

Abbreviations:AACE = American Association of Clinical EndocrinologistsAFF = atypical femur fractureASBMR = American Society for Bone and Mineral ResearchBEL = best evidence levelBMD = bone mineral densityBTM = bone turnover markerCBC = complete blood countCI = confidence intervalDXA = dual-energy X-ray absorptiometryEL = evidence levelFDA = U.S. Food and Drug AdministrationFLEX = Fracture Intervention Trial (FIT) Long-term ExtensionFRAX® = Fracture Risk Assessment ToolGFR = glomerular filtration rateGI = gastrointestinalHORIZON = Health Outcomes and Reduced Incidence with Zoledronic Acid Once YearlyIOF = International Osteoporosis FoundationISCD = International Society for Clinical DensitometryIU = international unitsIV = intravenousLSC = least significant changeNBHA = National Bone Health AllianceNOF = National Osteoporosis Foundation25(OH)D = 25-hydroxy vitamin DONJ = osteonecrosis of the jawPINP = serum carboxy-terminal propeptide of type I collagenPTH = parathyroid hormoneR = recommendationRANK = receptor activator of nuclear factor kappa-BRANKL = receptor activator of nuclear factor kappa-B ligandRCT = randomized controlled trialRR = relative riskS-CTX = serum C-terminal telopeptideSQ = subcutaneousVFA = vertebral fracture assessmentWHO = World Health Organization     

FASCICULATION—Electromyographic and Clinical Significance

Fascicular twitching of muscles may be present as the result of compression of spinal roots or anterior horn cells, injuries of peripheral nerves or plexes or to motor neuron disease. Occasionally fasciculation may be of no clinical significance.Electromyography may be of great help in determining the extent of involvement and whether other manifestations of nerve damage are present. Final diagnosis, however, depends upon the history, physical examination and clinical evaluation, since fasciculation is present in a wide variety of conditions.