Intracranial tumors simulating vascular lesions of the brain; a preliminary report

Occasionally in the presence of atypical symptoms it is difficult to distinguish between cerebrovascular disorders and intracranial tumors. Intracranial tumor should be suspected in cases of atypical symptoms of vascular lesion or even in typical cases in which the patient does not show expected improvement. In a group of eight cases the problem of differential diagnosis was not confined to those in which the patients were elderly. Furthermore, papilledema and elevated spinal fluid pressure were absent in all these cases. The absence of these signs, therefore, does not eliminate the possibility of an intracranial tumor.The electroencephalogram is an important adjunct in differential diagnosis. In this series, electroencephalograms lateralized the lesion correctly in every case and localized it in one. The importance of repeated electroencephalographic examination if wave patterns are normal in the first tracing was clearly illustrated in three instances.Ventriculography, which in six cases finally established the diagnosis, and the site of the lesion, should not be postponed unnecessarily.     

Therapeutic problems of nontoxic nodular goiter

The crucial point regarding non-toxic nodular goiter is the early diagnosis of neoplasm. A neoplasm may be suspected if a nodular goiter has shown recent growth with the concurrent appearance of pressure symptoms, if it is found in a patient under the age of 20, if vocal cord paralysis is present, or emphatically, if a solitary nodule is discovered. Such non-toxic nodular goiters should be promptly removed regardless of the presence or absence of pressure symptoms. If significant pressure symptoms are present, this in itself is an adequate reason for thyroidectomy.     

THERAPEUTIC PROBLEMS OF NON-TOXIC NODULAR GOITER

The crucial point regarding non-toxic nodular goiter is the early diagnosis of neoplasm. A neoplasm may be suspected if a nodular goiter has shown recent growth with the concurrent appearance of pressure symptoms, if it is found in a patient under the age of 20, if vocal cord paralysis is present, or emphatically, if a solitary nodule is discovered. Such non-toxic nodular goiters should be promptly removed regardless of the presence or absence of pressure symptoms. If significant pressure symptoms are present, this in itself is an adequate reason for thyroidectomy.     

Is There a Role for alpha-Blockers for the Treatment of Voiding Dysfunction Unrelated to Benign Prostatic Hyperplasia?

alpha-Adrenoreceptor antagonists have become the primary medical treatment for lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH). It was presumed that the primary mechanism by which alpha-blockers reduced lower urinary tract symptoms (LUTS) was by relaxation of smooth muscle in the prostate through a sympathetic response. Reduction of outlet resistance leads to changes in bladder function, thus improving both storage and voiding symptoms. However, it was observed that many patients with BPH-associated LUTS had significant improvement in storage symptoms without subjective or objective improvement in voiding. Storage symptoms associated with detrusor overactivity (frequency, urgency, and urge incontinence) are typically thought of as being parasympathetically mediated, and therefore anticholinergic medications have been the mainstay of pharmacological treatment, but recent work has suggested that several nonparasympathetic-mediated mechanisms may cause detrusor overactivity. Because alpha receptors appear to play a role in lower urinary tract function at multiple sites and levels, alpha-blockers could be used to treat voiding dysfunction not related to BPH. In addition, these nonprostate effects should be gender-independent, making the use of alpha-blockers plausible in women with specific types of voiding dysfunction.     

Pulmonary segmental resection for solitary lesions of doubtful character

Pulmonary cancer can be diagnosed earlier if patients with pulmonary symptoms of chronic type are given x-ray examination early, if patients over 40 years of age have a yearly roentgen examination of the chest regardless of their state of health, and if those with acute pulmonary illness are examined by x-ray within one month of the onset of illness. Observation of a known intrapulmonary lesion of unknown character should never last for more than one month. If it persists after that period, complete investigation, including thoracotomy, should be carried out if necessary to establish an exact diagnosis. A localized intrapulmonary lesion can be removed by segmental resection so that all healthy functioning lung is conserved if the disease is benign. If, after pathological examination, the lesion is shown to be cancerous, more radical resection can be carried out.     

PULMONARY SEGMENTAL RESECTION OF SOLITARY LESIONS OF DOUBTFUL CHARACTER

Pulmonary cancer can be diagnosed earlier if patients with pulmonary symptoms of chronic type are given x-ray examination early, if patients over 40 years of age have a yearly roentgen examination of the chest regardless of their state of health, and if those with acute pulmonary illness are examined by x-ray within one month of the onset of illness.Observation of a known intrapulmonary lesion of unknown character should never last for more than one month. If it persists after that period, complete investigation, including thoracotomy, should be carried out if necessary to establish an exact diagnosis. A localized intrapulmonary lesion can be removed by segmental resection so that all healthy functioning lung is conserved if the disease is benign. If, after pathological examination, the lesion is shown to be cancerous, more radical resection can be carried out.     

An evidence-based approach to the management of uninvestigated dyspepsia in the era of Helicobacter pylori

OBJECTIVES: To provide Canadian primary care physicians with an evidence-based clinical management tool, including diagnostic and treatment recommendations, for patients who present with uninvestigated dyspepsia. RECOMMENDATIONS: The management tool has 5 key decision steps addressing the following: (1) evidence that symptoms originate in the upper gastrointestinal tract, (2) presence of alarm features, (3) use of nonsteroidal anti-inflammatory drugs (NSAIDs), (4) dominant reflux symptoms and (5) evidence of Helicobacter pylori infection. All patients over 50 years of age who present with new-onset dyspepsia and patients who present with alarm features should receive prompt investigation, preferably by endoscopy. The management options for patients with uninvestigated dyspepsia who use NSAIDs regularly are: (1) to stop NSAID therapy and assess symptomatic response, (2) to treat with NSAID prophylaxis if NSAID therapy cannot be stopped or (3) to refer for investigation. Gastroesophageal reflux disease can be diagnosed clinically if the patient''s dominant symptoms are heartburn or acid regurgitation, or both; these patients should be treated with acid suppressive therapy. The remaining patients should be tested for H. pylori infection, and those with a positive result should be treated with H. pylori-eradication therapy. Those with a negative result should have their symptoms treated with optimal antisecretory therapy or a prokinetic agent. VALIDATION AND EVIDENCE: Evidence for resolution of the dyspepsia symptoms was the main outcome measure. Supporting evidence for the 5 steps in the management tool and the recommendations for treatment were graded according to the strength of the evidence and were endorsed by consensus of committee members. If no randomized controlled clinical trials were available, the recommendations were based on the best available evidence. LITERATURE REVIEW: Evidence was obtained from MEDLINE searches for pertinent articles published from 1966 to October 1999. The searches focused on dyspepsia, diagnosis and treatment. Additional articles were retrieved through a manual search of bibliographies and abstracts from international gastroenterology conferences.     

An infant with diaphragmatic eventration and respiratory distress

The authors report a rare case of partial diaphragmatic eventration in a 4-month-old infant with recurrent wheezing and low serum IgA values. Because of persistent respiratory symptoms after therapy with inhaled short-acting beta2 agonists and inhaled nebulized corticosteroids, surgery was undertaken to correct the defect. Despite surgery, the clinical symptoms did not improve. Consequently, gatroesophagel reflux was considered and the diagnosis was confirmed with pH-metry, after which the infant was started on a protonic pump inhibitor therapy (PPI), achieving clinical improvement. Our experience suggests that in infants with congenital diaphragmatic eventration who present with respiratory distress gastro-oesophageal reflux should be suspected, and PPI therapy should be started before planning surgery.     

Subacute thyroiditis presenting as Cushing's syndrome. Case report.

Subacute thyroiditis is a benign, self-limited disorder characterized by hyperthyroidism that resolves spontaneously. Although cortisol metabolism is accelerated in hyperthyroidism, cortisol levels are usually normal. We describe a child with subacute thyroiditis whose presenting complaints and preliminary evaluation suggested a diagnosis of Cushing's syndrome. There was spontaneous improvement in the signs and symptoms with concomitant normalization of laboratory values. We conclude that hypercortisolism may be a manifestation of hyperthyroidism, and the evaluation of Cushing's syndrome should include thyroid function tests.     

Sciatic Injection Neuropathy

Prevention of sciatic injection neuropathy can best be accomplished by teaching that the injection should be made into the gluteal mass in the upper outer quadrant rather than the buttock, and that the needle should be introduced in a plane perpendicular to the surface of the bed when the patient is lying prone. Failing prevention, one must strive for early and correct diagnosis, especially in infants, and carry out exploration with internal and external neurolysis if there is no evidence of improvement within two to three months.     

Micro analysis of metals in dental restorations as part of a diagnostic approach in metal allergies

In dentistry, a variety of potentially allergenic metals are used, such as mercury, palladium, nickel, gold, chromium, cobalt and other metals. This paper describes a diagnostic approach from a dentist's point of view, which enables analysis of metals in a patient's oral cavity. If metal allergy is suspected, a micro analysis can be used to determine which metals are present in the restorations. When the exact composition of the dental materials is known, the patient can be tested in vivo (patch test) and/or in vitro (lymphocyte proliferation test) to reveal sensitization. Two patients with nickel allergy are described where removal of nickel-containing materials (bridge and orthodontic wire) resulted in the marked alleviation of symptoms and improvement of health. Finally, if allergy to specific metals has been established, the restorations containing the implicated metals should be removed to discontinue the exposure and thus facilitate the patient's health.     

Cerebral thrombosis and embolism; a method of treatment

Acute cerebral thrombosis and embolism give rise to arterial spasm, edema, and anoxia of the cerebral tissues supplied by the affected artery or arteries. Sympathetic block induced by injecting the stellate ganglion with procaine appears to relieve spasm and results in improved cerebral circulation and clinical improvement in a significant number of cases. Sympathetic block should be combined with the usual supportive measures and not infrequently with anticoagulants. Every effort should be made to institute treatment as soon as possible after the onset of symptoms.     

CEREBRAL THROMBOSIS AND EMBOLISM—A Method of Treatment

Acute cerebral thrombosis and embolism give rise to arterial spasm, edema, and anoxia of the cerebral tissues supplied by the affected artery or arteries. Sympathetic block induced by injecting the stellate ganglion with procaine appears to relieve spasm and results in improved cerebral circulation and clinical improvement in a significant number of cases. Sympathetic block should be combined with the usual supportive measures and not infrequently with anticoagulants. Every effort should be made to institute treatment as soon as possible after the onset of symptoms.     

Neuromodulation for the treatment of refractory interstitial cystitis

Interstitial cystitis (IC) is a symptom complex of urinary urgency, frequency and pelvic pain. Multimodality behavioral and phamacologic treatment is often effective in treating IC. Unfortunately, some patients with IC are refractory to standard treatments. Neuromodulation has been shown to be effective in treating voiding dysfunction. Small studies have demonstrated improvement in pelvic pain and IC symptoms during temporary sacral nerve stimulation. This current study demonstrates that patients refractory to traditional therapies for IC can respond well to sacral nerve stimulation and maintain improvement in symptoms after permanent implantation of a neurogenerator. The technique used to place the neurostimulator can impact on the degree of the response and the complication rate. Sacral neurostimulation continues to evolve and should be in the armamentarium available to treat voiding dysfunction.     

Small Bowel Obstruction Due to Intramural Hematoma During Anticoagulant Therapy—A Non-Surgical Condition

Intramural hematoma of the small bowel should be suspected in any patient with signs or symptoms of small bowel obstruction who is having anticoagulant drug therapy, especially if it is longterm therapy and if the prothrombin time is excessively prolonged. A barium study is indicated and if the roentgen pattern is characteristic, conservative treatment is indicated. Unless there is an associated abdominal lesion requiring operation, most patients will improve in four to six days. Those not improving usually have other complicating conditions.     

Additional comments on migraine therapy

The symptoms and clinical management of alcohol, barbiturate and benzodiazepine withdrawal syndromes are discussed in this article. People who suffer alcohol withdrawal should be admitted to hospital if they have medical or surgical complications or severe symptoms; supportive care and pharmacotherapy, especially diazepam loading, are the essential components of treatment. Barbiturate withdrawal requires pharmacotherapy and admission to hospital for patients who have taken more than 0.4 g/d of secobarbital or an equivalent amount of another barbiturate for 90 days or longer, or 0.6 g/d or an equivalent dose for 30 days or longer, or who have had withdrawal seizures or delirium; phenobarbital loading is recommended. Regular benzodiazepine therapy that has lasted at least 3 months should be gradually stopped. Short-acting agents should be replaced with long-acting ones, such as diazepam, to avoid withdrawal symptoms. Most of these patients can be managed on an outpatient basis.     

NEUROSURGERY IN GENERAL PRACTICE

The advances in the field of neurological surgery permit satisfactory treatment of problems heretofore looked upon as nonremediable. Visible abnormalities of the head should be analyzed carefully for neurological implications and possibilities of correction. The relief of pain by specific pain pathway interruption can be both gratifying and merciful, and if it is to be carried out, should not be withheld until the terminal stages of disease. Common symptoms such as epilepsy and subarachnoid hemorrhage deserve full scale investigation with an eye to elucidation of the causative factors and proper therapy.     

Should symptomatic menopausal women be offered hormone therapy?

Many physicians remain uncertain about prescribing hormone therapy for symptomatic women at the onset of menopause. The American Society for Reproductive Medicine (ASRM) convened a multidisciplinary group of healthcare providers to discuss the efficacy and risks of hormone therapy for symptomatic women, and to determine whether it would be appropriate to treat women at the onset of menopause who were complaining of menopausal symptoms. MAJOR FINDINGS: Numerous controlled clinical trials consistently demonstrate that hormone therapy, administered via oral, transdermal, or vaginal routes, is the most effective treatment for vasomotor symptoms. Topical vaginal formulations of hormone therapy should be preferred when prescribing solely for the treatment of symptoms of vulvar and vaginal atrophy. Data from the Women's Health Initiative indicate that the overall attributable risk of invasive breast cancer in women receiving estrogen plus progestin was 8 more cases per 10,000 women-years. No increased risk for invasive breast cancer was detected for women who never used hormone therapy in the past or for those receiving estrogen only. Hormone therapy is not effective for the treatment of cardiovascular disease and that the risk of cardiovascular disease with hormone therapy is principally in older women who are considerably postmenopause. CONCLUSIONS: Healthy symptomatic women should be offered the option of hormone therapy for menopausal symptoms. Symptom relief with hormone therapy for many younger women (at the onset of menopause) with menopausal symptoms outweighs the risks and may provide an overall improvement in quality of life. Hormone therapy should be individualized for symptomatic women. This involves tailoring the regimen and dose to individual needs.     

Should symptomatic menopausal women be offered hormone therapy?

Many physicians remain uncertain about prescribing hormone therapy for symptomatic women at the onset of menopause. The American Society for Reproductive Medicine (ASRM) convened a multidisciplinary group of healthcare providers to discuss the efficacy and risks of hormone therapy for symptomatic women, and to determine whether it would be appropriate to treat women at the onset of menopause who were complaining of menopausal symptoms. MAJOR FINDINGS: Numerous controlled clinical trials consistently demonstrate that hormone therapy, administered via oral, transdermal, or vaginal routes, is the most effective treatment for vasomotor symptoms. Topical vaginal formulations of hormone therapy should be preferred when prescribing solely for the treatment of symptoms of vulvar and vaginal atrophy. Data from the Women's Health Initiative indicate that the overall attributable risk of invasive breast cancer in women receiving estrogen plus progestin was 8 more cases per 10,000 women-years. No increased risk for invasive breast cancer was detected for women who never used hormone therapy in the past or for those receiving estrogen only. Hormone therapy is not effective for the treatment of cardiovascular disease and that the risk of cardiovascular disease with hormone therapy is principally in older women who are considerably postmenopause. CONCLUSIONS: Healthy symptomatic women should be offered the option of hormone therapy for menopausal symptoms. Symptom relief with hormone therapy for many younger women (at the onset of menopause) with menopausal symptoms outweighs the risks and may provide an overall improvement in quality of life. Hormone therapy should be individualized for symptomatic women. This involves tailoring the regimen and dose to individual needs.     

Detection of multiple colon and rectal tumors during diagnostic treatment and follow-up

Recognition of the commonly encountered colorectal cancer (CRC) generally begins and takes place because of and based on symptoms and signs, due to the unsettled screening of this type of cancer. Sometimes, because of advanced stage cancer urgent surgical intervention could become necessary and, if this is the case, there is no time and possibility for searching for an eventual second tumor and perhaps the patient's status does not permit performing intraoperative investigations either. The incidence of multiple colon cancer is considered to be between 2.5 and 30% according to the literature. That is why one should exclude them even in the absence of pre- and intraoperative investigations and complaints. On the other hand, colonoscopy and perhaps irrigoscopy of seemingly healthy followed-up patients is mandatory. In the case of the presence of complaints/symptoms denoting impaired intestinal passage seen in a followed-up patient or during the adjuvant setting or metastatic/recurrent disease, treatment and even during hospice care we should evaluate the possibility of a second metachronous tumor. Moreover, if there is no urgency, the multidisciplinary team (oncoteam) should recommend the adequate treatment by balancing gain/utility and risk.