RHEUMATOID ARTHRITIS—Diagnosis in Peripheral Joint Affliction

The diagnosis of rheumatoid arthritis in a typical case depends upon a history of pain and swelling of various joints throughout the body. In the first stages the disease usually involves only the small joints of the hands and feet, but sooner or later it spreads to the larger joints. This may be accompanied by fibrosis of one or more joints, causing disability ranging from disuse of one joint up to total incapacity. Diagnosis in early or atypical cases is often impossible until the patient has been under observation a long time. It is important that diagnosis be made as early as possible, in order that appropriate therapy may be started and ankylosis and disability of the joints prevented.Since laboratory procedures and roentgen films do not show early changes, emphasis is placed on the history and physical examination for diagnosis.     

Rheumatoid arthritis; diagnosis in peripheral joint affliction

The diagnosis of rheumatoid arthritis in a typical case depends upon a history of pain and swelling of various joints throughout the body. In the first stages the disease usually involves only the small joints of the hands and feet, but sooner or later it spreads to the larger joints. This may be accompanied by fibrosis of one or more joints, causing disability ranging from disuse of one joint up to total incapacity. Diagnosis in early or atypical cases is often impossible until the patient has been under observation a long time. It is important that diagnosis be made as early as possible, in order that appropriate therapy may be started and ankylosis and disability of the joints prevented. Since laboratory procedures and roentgen films do not show early changes, emphasis is placed on the history and physical examination for diagnosis.     

Bone and joint tuberculosis: a continuing problem.

Although tuberculous disease of bones and joints is becoming uncommon, it still occurs and may cause devastating sequelae. It is frequently not diagnosed prior to the onset of permanent damage to the joints or spine; the most important reason for this delay may be the fact that it is not considered in the differential diagnosis of monoarthritis or back pain. Most persons with the disease have other evidence of tuberculosis. Not infrequently an aggressive approach (including synovial biopsy or surgical exploration of the back) is needed to confirm the diagnosis when there are no other clues.     

RHEUMATOID (MARIE-STRUMPELL) SPONDYLITIS,Technique of Examination and Importance of the Costal Joints

Rheumatoid spondylitis in the early prodromal stage may present a complex and obscure clinical picture making diagnosis difficult. It is in this early stage that roentgen examination of the small joints of the spine will often aid in or lead to the correct diagnosis of the disease in which the classical clinical symptoms and roentenographic findings in the sacroiliac fissure have not appeared and may never appear. The changes in these small joints, particularly in the costovertebral and costotransverse joints, are less obvious and require experienced and careful interpretation, but it is to these that the roentgenologist must direct his attention if he is to be of assistance in early diagnosis. A technical procedure for this examination is presented, along with a discussion of the clinical importance of changes at this site.Demonstration of involvement of the sacroiliac joints is of diagnostic importance, but this finding is no more necessary to the diagnosis of rheumatoid spondylitis than is involvement of any other single joint of the spine. Insistence on sacroiliac involvement will often result in missed diagnosis, and has led in part to erroneous conclusions as to sex incidence of the disease.     

Rheumatoid (Marie-Strumpell) spondylitis; technique of examination and importance of the costal joints

Rheumatoid spondylitis in the early prodromal stage may present a complex and obscure clinical picture making diagnosis difficult. It is in this early stage that roentgen examination of the small joints of the spine will often aid in or lead to the correct diagnosis of the disease in which the classical clinical symptoms and roentenographic findings in the sacroiliac fissure have not appeared and may never appear. The changes in these small joints, particularly in the costovertebral and costotransverse joints, are less obvious and require experienced and careful interpretation, but it is to these that the roentgenologist must direct his attention if he is to be of assistance in early diagnosis. A technical procedure for this examination is presented, along with a discussion of the clinical importance of changes at this site. Demonstration of involvement of the sacroiliac joints is of diagnostic importance, but this finding is no more necessary to the diagnosis of rheumatoid spondylitis than is involvement of any other single joint of the spine. Insistence on sacroiliac involvement will often result in missed diagnosis, and has led in part to erroneous conclusions as to sex incidence of the disease.     

The Management of Benign Bone Lesions

The almost bewildering variety of lesions that can affect bone contrasts sharply with the limited potential of bone to differentially respond to those lesions. This paradox can create a challenging problem when a bone lesion is shown on an x-ray film. Although heavily populated with pleuripotential primitive mesenchymal cells, there is seldom a histologic or radiographic change in the involved bone specific enough to allow a comfortable diagnostic autonomy to be enjoyed by surgical pathologists, radiologists or orthopaedic surgeons. Even when diligent and astute clinical evaluation has excluded infectious, parasitic, metabolic and metastatic causes of the change seen on x-ray studies, a physician is often still uncertain as to the exact nature of the lesion. A knowledge of the relative frequency of the common lesions, an acceptance that biopsy studies and treatment must be combined at times, an appreciation of the possibility of malignant change in a given lesion and a tendency to seek early consultation will likely lead to timely and accurate diagnosis. Once the diagnosis is made, optimum management must be selected. The best current opinion categorizes the lesions into treatment groups consisting of observation, curettage and graft, block excision, cryotherapy and radiotherapy.     

Intestinal obstruction

Despite improvements in knowledge of the pathologic physiology of intestinal obstruction, the introduction of gastrointestinal decompression, and more effective antibiotics, obstruction remains a serious disease with a high mortality rate. Although the diagnosis is often obscure, it can usually be made with a fair degree of accuracy by the history alone; pain is fairly constant and characteristically is of a cramping type simulated by very few other lesions. Distention is present in low lesions but absent in high lesions; on the contrary, vomiting is minimal in low lesions but prominent in high lesions. Visible peristaltic waves are almost pathognomonic of intestinal obstruction. Increased peristaltic sounds, as noted by auscultation, are extremely helpful in diagnosis; they are absent in paralytic ileus. Although intestinal obstruction is a surgical lesion, it must be remembered that in the type produced by adhesions the obstruction can be relieved by gastrointestinal decompression in 80 to 90 per cent of cases. Operation is usually indicated a short time after relief because of the probability of recurrence. In practically all other types of obstruction decompression is indicated only while the patient is being prepared for operation. Obviously any type of strangulation demands early operation. Strangulation can usually be diagnosed, particularly if it develops while the patient is under observation. Increase in pain, muscle spasm and pulse rate are important indications of development of strangulation. Dehydration and electrolytic imbalance are produced almost universally in high obstruction. Usually, it is unwise to wait until these two deficiencies are corrected before operation is undertaken, but correction must be well under way at the time of operation. Resections should be avoided in the presence of intestinal obstruction, but obviously will be necessary in strangulation. Operative technique must be expert and carried out with minimal trauma. Postoperative care is very important; important features are decompression, for two to three days, accurate fluid and electrolytic replacement, and transfusions.     

INTESTINAL OBSTRUCTION

Despite improvements in knowledge of the pathologic physiology of intestinal obstruction, the introduction of gastrointestinal decompression, and more effective antibiotics, obstruction remains a serious disease with a high mortality rate. Although the diagnosis is often obscure, it can usually be made with a fair degree of accuracy by the history alone; pain is fairly constant and characteristically is of a cramping type simulated by very few other lesions. Distention is present in low lesions but absent in high lesions; on the contrary, vomiting is minimal in low lesions but prominent in high lesions. Visible peristaltic waves are almost pathognomonic of intestinal obstruction. Increased peristaltic sounds, as noted by auscultation, are extremely helpful in diagnosis; they are absent in paralytic ileus.Although intestinal obstruction is a surgical lesion, it must be remembered that in the type produced by adhesions the obstruction can be relieved by gastrointestinal decompression in 80 to 90 per cent of cases. Operation is usually indicated a short time after relief because of the probability of recurrence. In practically all other types of obstruction decompression is indicated only while the patient is being prepared for operation. Obviously any type of strangulation demands early operation. Strangulation can usually be diagnosed, particularly if it develops while the patient is under observation. Increase in pain, muscle spasm and pulse rate are important indications of development of strangulation.Dehydration and electrolytic imbalance are produced almost universally in high obstruction. Usually, it is unwise to wait until these two deficiencies are corrected before operation is undertaken, but correction must be well under way at the time of operation. Resections should be avoided in the presence of intestinal obstruction, but obviously will be necessary in strangulation. Operative technique must be expert and carried out with minimal trauma. Postoperative care is very important; important features are decompression, for two to three days, accurate fluid and electrolytic replacement, and transfusions.     

结核性脑膜炎的诊断和治疗

结核性脑膜炎(TBM)是一种严重的肺外结核性,约占全部结核病的1%。TBM的死亡率和致残率高,至今仍是发展中国家最严重的疾病之一。儿童患者及合并HIV感染的结核性脑膜炎患者死亡率明显增高。结核性脑膜炎的具体发病机制仍不清楚,细菌和宿主的遗传因素在结脑的发病机制中发挥了至关重要的作用。尽管现代医学技术的进展,TBM的早期诊断仍存在困难。TBM的诊断依赖于临床表现、实验室检查以及影像学检查,脑脊液细菌涂片或培养找到结核分枝杆菌可确诊。早期诊断和治疗尤为关键。临床上往往从经验判断开始抗结核治疗。WHO指南推荐至少六个月的抗结核治疗。然而,部分指南推荐延长抗结核治疗至9-12个月。早期使用类固醇类激素可降低死亡率。抗结核药物耐药性与高死亡率相关。该综述描述了结脑的各个方面,重点强调结核性脑膜炎的早期诊断和治疗。     

软骨寡聚基质蛋白在关节炎中的作用

研究表明在骨性关节炎和类风湿性关节炎患者血清中软骨寡聚基质蛋白(cartilage oligomeric matrix protein,COMP)可以在出现关节形态学改变以前就在生化代谢方面表现异常,为早期诊断提供了新思路,其可以作为反映早期关节软骨破坏和骨关节疾病急性活动程度的指标。从而能在病变不可逆发展之前及早防治,逆转或延缓病变进展。COMP是关节炎疾病的诊断与判断疾病进展和缓解潜在生物学标志物。本文就软骨寡聚基质蛋白及其在关节炎中的作用作一综述。     

CEREBRAL ANGIOGRAPHY—Its Use in Acute Head Injuries and Undiagnosed Coma

One of the major factors in treating a patient with acute alteration of consciousness is to determine if progressive intracranial hemorrhage is present. Similar problems are encountered in cases of cerebrovascular disease where increasingly effective medical and surgical methods of treatment are available. Progressive cerebral thrombosis can be arrested by anticoagulants, intracranial hemorrhage can be controlled and atheromatous occlusion of a major artery can be corrected. Intracranial mass lesions can be detected when the history is not available or is misleading.Cerebral angiography is a relatively safe diagnostic test that is certainly preferable to delayed or haphazard treatment when an exact diagnosis is uncertain in an unconscious patient.     

Cutaneous melanoma: digital dermoscopy-essential tool for positive diagnosis

Cutaneous melanoma is a "perfid", aggressive and hard to be treated malignant tumor in case of delayed diagnosis. However, patients still have a chance to escape progressive disease if the lesion is recognized early, when the surgical approach is curative. Dermoscopy has the important advantage of rapidity and non-invasivity in a field with (still) contradictory algorithms of diagnosis and treatment. The recognition of the elementary dermoscopic lesions enables accurate diagnosis for cutaneous melanoma. In our opinion, dermoscopy appears compulsory in the routine dermatologic examination. In vivo microscopy (dermoscopy) together with histopathology (plus or minus immunohistochemistry) seem, at present, to provide the most reliable diagnosis of melanoma.     

EARLY DIAGNOSIS OF MALIGNANT MELANOMA OF THE SKIN

About five per cent of all malignant lesions of the skin are malignant melanomas. The poor prognosis associated with this malignant lesion emphasizes the importance of early diagnosis. A large proportion of malignant melanomas arise in preexisting lesions such as junction nevi, precancerous melanoses and, much more rarely, blue nevi. Early malignant changes in these precursor lesions include increasing pigmentation, enlargement, thickening, crusting, bleeding, ulceration, tumor formation, and development of satellite lesions.Many pigmented, and some non-pigmented, lesions of the skin must be differentiated from malignant melanoma. Since even with radical surgical treatment the prognosis of malignant melanoma is poor, junction nevi which are subject to continual trauma or have signs of probable malignant degeneration should be prophylactically excised.     

A report of six cases

Six cases of gonococcal arthritis are described. Three presented during the initial “bacteremic stage” with polyarthralgia, fever, skin lesions and sterile synovial fluid. Two presented during the “septic joint stage” with positive synovial culture, and one presented during the “stage of residual deformity”. Transient electrocardiographic changes were noted in two of the six cases. All responded to antibiotic therapy. One required additional surgical intervention.The condition is common, coinciding with the rising incidence of symptomatic and asymptomatic gonorrhea. Gonococcal infection must be considered in the differential diagnosis of migratory polyarthralgia, tenosynovitis, oligoarthritis, fever or unusual skin lesions. Criteria for diagnosis, lines of treatment and relevant literature are reviewed.     

Radiation diagnosis for tuberculous gonitis in children

Tuberculous knee joint lesion in children is the most common form of articular pathology. The high sociomedical significance of this disease in modern society is determined by not only its prevalence, but also economic losses caused by high disability rates in children. The purpose of the study was to determine the possibilities and place of a comprehensive radiation study in the diagnosis of tuberculous gonitis in children. Sixty patients aged 10 months to 18 years were examined. Clinical studies were comprehensively assessed, by taking into account the collected history data and orhthopedic and laboratory findings. Surgery was made in 26 children. All the patients underwent mutiprojection X-ray study, knee joint ultrasound study being made in 48 patients. Knee joint X-ray study was performed on Siregraph (Siemens) apparatuses. Real-time ultrasonography was conducted on Aloka SSD-1100 and Aloka--3500+ apparatuses, by employing a 7.5-MHz linear transducer. According to P.G. Kornev (1971), three phases were identified in the course of tuberculous gonitis. These included prearthritic (the development of primary ostitis); arthritic (articular cartilage destruction, followed by the development of secondary arthritis; and postarthritic (sequels of prior tuberculous osteomyelitis) phases. Analysis indicated that the use of the routine X-ray study in combination with ultrasound scanning in the diagnosis of tuberculous gonitis in children yielded more adequate information on tissue and knee joint structural changes and made it possible to define further policy treatment and to predict the outcomes of the disease.     

Retrospective study of children with renal scarring associated with reflux and urinary infection.

OBJECTIVE--To review the histories of children with bilateral renal scarring and severe vesicoureteric reflux to determine whether an improvement in early management might reduce the risk of scarring. DESIGN--Retrospective study of medical records and discussion with parents. SETTING--Outpatient departments of two teaching hospitals. PATIENTS--52 children aged 1-12 years participating in a randomised comparison of medical and surgical management. All had a history of symptomatic urinary tract infection. Two thirds presented with fever and two with hypertension or renal failure. In only one out of 32 children examined by antenatal ultrasonography was an abnormality suspected. RESULTS--There was delay in diagnosis or appropriate imaging or effective treatment of urinary infection in 50 of the 52 children. In 41 there was delay in diagnosis; there was delay in treating a confirmed infection in 45; no antibacterial prophylaxis was prescribed before imaging in 28; and investigation of the urinary tract was delayed in 33. The severity of scarring was significantly related to delay in diagnosis (chi 2 for trend 7.43, P = 0.01). Four children of mothers known to have reflux nephropathy were not investigated until they developed urinary tract infection. CONCLUSIONS--Efforts to reduce the incidence and severity of renal scarring should be directed towards rapid diagnosis and effective early management of urinary tract infection in infancy and childhood. Siblings and offspring of known patients with severe reflux nephropathy should be investigated for reflux.     

The present status of tranquilzing drugs

In the program of research into the natural history of coalworkers' pneumoconiosis now being carried out in Great Britain, emphasis is being put upon the importance of sharpening and validating means for early diagnosis, and upon the need for follow-up studies upon properly selected population samples. Existing information from morbidity and mortality figures from chronic bronchitis and emphysema in Great Britain suggests that atmosphere pollutants are important etiological factors. A parallel is drawn between the course of events in pneumoconiosis, in which dust retention in the lungs does not greatly disable until complicated by tuberculous infection, and a hypothesis that bronchitis is a hypersecretion of bronchial mucus caused by atmospheric irritants and does not disable but encourages secondary infection which may cause emphysema. This hypothesis requires testing by follow-up studies of population samples exposed to various environmental influences. It is suggested that in order to bring this common and disabling disease under control, clinicians must widen their interests beyond the confines of the hospital walls.     

CHRONIC DISABLING RESPIRATORY DISEASE—Ends and Means of Study

In the program of research into the natural history of coalworkers'' pneumoconiosis now being carried out in Great Britain, emphasis is being put upon the importance of sharpening and validating means for early diagnosis, and upon the need for follow-up studies upon properly selected population samples. Existing information from morbidity and mortality figures from chronic bronchitis and emphysema in Great Britain suggests that atmosphere pollutants are important etiological factors. A parallel is drawn between the course of events in pneumoconiosis, in which dust retention in the lungs does not greatly disable until complicated by tuberculous infection, and a hypothesis that bronchitis is a hypersecretion of bronchial mucus caused by atmospheric irritants and does not disable but encourages secondary infection which may cause emphysema. This hypothesis requires testing by follow-up studies of population samples exposed to various environmental influences. It is suggested that in order to bring this common and disabling disease under control, clinicians must widen their interests beyond the confines of the hospital walls.     

TREATMENT OF GENITO-URINARY TUBERCULOSIS WITH STREPTOMYCIN AND SYNERGISTIC DRUGS

The use of newer drugs in the treatment of genito-urinary tuberculosis is usually auxiliary to accepted surgical and medical procedures. The treatment of choice is removal of the tuberculous focus by surgical methods whenever this can be achieved. Risk of tuberculous complications of surgical operation may be greatly reduced by the use of these drugs. There is also a significant place for such treatment when disease is too far advanced to permit surgical removal. Under these conditions, the principal result is one of palliation only in many circumstances. The drugs of choice at this time are a combination of streptomycin and para-aminosalicylic acid (PAS) and the treatment is frequently more prolonged than in the case of tuberculosis of other organs.     

The evaluation of contrast-enhancing brain lesions: pitfalls in current practice

The definitive diagnosis of space-occupying brain lesions can be established more readily since the advent of computerized tomographic (CT) scanning. Some brain lesions are more clearly defined when contrast-enhancing agents are utilized; however, so-called ring-enhancing lesions are not pathognomonic for specific neurological entities. Review of the literature suggests that at least four disorders must be considered in the differential diagnosis of contrast-enhancing lesions. These include mature brain abscesses of any etiology, cerebrovascular accidents, and primary or metastatic brain tumors. Since the medical and surgical management of these conditions is quite different, it is critical to establish a diagnosis before therapy is instituted. In many instances the combination of history, physical examination, laboratory, and radiologic examination will enable physicians to correctly diagnose the etiology of such brain lesions. However, we present two cases for which the above clinical and non-invasive parameters led to incorrect working diagnoses. Brain biopsy was required before appropriate management was eventually instituted. Potentially, such delays in diagnosis and institution of therapy can result in unnecessary morbidity and mortality. Each case illustrates the need to substantiate a presumptive diagnosis based on these clinical and radiographic criteria, regardless of how "typical" lesions may appear on CT scans.