Oral disease epidemiologic illness indices and oral health measures--traditional concepts are supplemented by new socio-dental indicators

The approach to patients with chronic cough has been well defined and evaluated in the literature through a number of prospective studies. Meticulous attention to detail of the afferent loop of the cough reflex has helped identify the cause of cough in most patients. The most common causes appear to be similar in both children and adults and include asthma, postnasal drip syndromes, gastroesophageal reflux diseases, and aspiration. In children, recurrent viral infections and infections with atypical organisms also are very prevalent. Specific therapy directed at the cause alleviates the cough in most patients. In some patients, there may be more than one cause of cough. Invasive testing (eg, bronchoscopy and esophageal pH probing) is rarely necessary. In patients in whom a specific cause cannot be identified or in whom cough modifiers are necessary while specific therapy is taking hold, antitussives of both the narcotic and nonnarcotic variety are helpful.     

Assessment of the patient with chronic cough

Chronic cough, defined as cough that persists for 3 weeks or longer, is one of the most common symptoms evaluated by a primary-care physician. With the exclusion of cigarette smoking, postnasal drip, asthma, and gastroesophageal reflux are responsible for more than 80% of the causes of chronic cough. Elicitation of a thorough history and performance of a physical examination will usually provide clues about the cause of chronic cough. The use of diagnostic tests including methacholine challenge, gastroesophageal reflux studies, and sinus imaging is based on clinical suspicion. Treatment of chronic cough is aimed at the underlying cause.     

The erythrocyte sedimentation rate. Still a helpful test when used judiciously

ESR is a time-honored, simple, inexpensive test, but unfortunately it lacks sensitivity and specificity. Clinicians need to be aware of appropriate uses, because any test is expensive when ordered often, and evaluation of false-positive results may incur substantial costs and place the patient at risk from additional procedures. ESR should not be used to screen asymptomatic persons for disease. If an increased ESR is encountered and no explanation is immediately apparent, clinicians should repeat the test in several months rather than pursue an exhaustive search for occult disease. ESR may be useful in establishing a "sickness index" in elderly persons who have nonspecific changes in health status and a moderate probability of underlying disease; in screening for infection in specific settings (e.g., orthopedic surgery, pediatrics, gynecology); in diagnosing and monitoring temporal arteritis, polymyalgia rheumatica, and possibly other rheumatic diseases; in monitoring patients with treated Hodgkin's disease; and in assessing iron deficiency in anemia of chronic disease (when correlated with serum ferritin level). An ESR value exceeding 100 mm/hr has a 90% predictive value for serious underlying disease, most often infection, collagen vascular disease, or metastatic tumor. In asymptomatic persons with a markedly elevated ESR value, a minimal number of tests usually reveal the cause.     

Improving nursing education classroom environments

To study the characteristics of our outpatient clinic patients presenting with chronic cough as the sole symptom of bronchial asthma, and to evaluate the bronchial hyperreactivity of such patients in comparison with that of classic asthmatic patients with normal spirometry. For 3 years we studied 193 consecutive patients with chronic cough as the sole symptom, using the study protocol specified in the section on patients and methods. Sixty-three patients were diagnosed of bronchial asthma. Bronchial hyperreactivity was considered to be the cause of coughing based on reversibility testing or a positive methacholine test, along with response to specific antiasthmatic therapy. Forty-six (73%) of the 63 patients had unproductive cough and 28 (44%) coughed mainly at night. In 14 (22%) symptoms began with an upper respiratory tract infection. Wheezing could be heard in only 4 (6%). Diagnosis was based on reversibility in 11 (17%) and methacholine testing in 52 (83%). Mean PC20 was higher in patients diagnosed of variant cough. Unlike classic asthma, persistent and usually unproductive cough caused by asthma has few or no accompanying symptoms. The diagnostic yield of methacholine testing is high in such patients.     

Inflammatory pain: the role of cytokines and its control by drugs which release nitric oxide

Chronic cough is a common symptom in many different disease processes. Because the most effective way to eliminate a chronic cough is to identify and treat the underlying disease, the physician must approach the paediatric patient based on his or her knowledge of the differential diagnosis. The most common causes of cough in children are upper respiratory tract infections, asthma, rhinitis, sinusitis, and gastroesophageal reflux. By using a systematic approach, the cause of a chronic cough can almost always be found, and the cough successfully treated. Asthma is the cause of most undiagnosed chronic coughs but sinusitis, rhinitis, and gastroesophageal reflux must also be considered in difficult patients.     

Alpha 1-antitrypsin deficiency and asthma. The continuing search for the relationship

Patients with alpha 1-antitrypsin (AAT) deficiency, like those with asthma and chronic obstructive pulmonary disease, usually present with dyspnea, wheeze, and cough. The similarity in presentation and unfamiliarity among clinicians with AAT deficiency account for much of the delay in diagnosis. Normally, AAT inhibits serine proteases, which cause alveolar destruction, and alters the function of cells that release mediators of inflammation. Diagnostic findings suggesting deficiency include irreversible airflow obstruction, a decreased diffusing capacity of the lung for carbon monoxide, bibasilar bullous disease on chest films, and a low serum level of AAT. Asthma is usually diagnosed on the basis of clinical findings and response to inhaled beta agonists. The presence of inflammation is believed to be necessary for development of clinically significant asthma. Inflammation added to a deficiency of antiprotease inhibitor activity significantly worsens bronchial hyperreactivity. This is only one mechanism by which AAT deficiency may potentiate allergic and bronchospastic responses. The prevalence of bronchial asthma in patients with AAT deficiency is unknown. Studies by the National Institutes of Health regarding the natural history of AAT deficiency and its response to therapy are under way. Perhaps more will be discovered about the relationship between the disorder and bronchial asthma.     

Achilles tendinitis

Achilles tendinitis is a common condition of overuse seen in active individuals. It is multifactorial, usually due to a combination of anatomic and biomechanical characteristics along with poor training technique. Pathologic changes can involve the surrounding tissue (bursae, paratenon) or the tendon itself and can occur both at its insertion into the calcaneous and the critical hypovascular zone. A clear understanding of the cause and stage of the condition is critical for successful treatment, be it conservative or surgical. Recent advances in surgical technique and postoperative rehabilitation have been promising in returning individuals to their previous levels of activity.     

Actinomycosis of the posterior triangle: a case report and review of the literature

Actinomycosis presents acutely as an abscess, or as a chronic lesion mimicking malignancy, tuberculosis, or aspergillosis. Most disease involves the mouth and its immediate site of lymphatic drainage, the anterior triangle of the neck. We present a case of actinomycosis at the apex of the posterior triangle, suspected of being a malignancy, and discuss the importance of being aware of this as a cause of neck lumps. The diagnosis is usually made late because of the difficulties in culturing the organism, or in identifying characteristic 'sulphur granules' in pus or biopsy specimens. For these reasons, the disease is underdiagnosed. When acute or chronic neck lesions prove difficult to diagnose, microscopy and prolonged anaerobic culture of pus and biopsy specimens should be performed in addition in Ziehl-Neelsen staining, tuberculosis and fungal cultures. The tests should be repeated if negative. Specific treatment requires prolonged courses of antibiotics, despite adequate surgical excision, to prevent relapse.     

Complications of endonasal paranasal sinus surgery--diagnostic and therapeutic consequences

BACKGROUND: Functional endoscopic sinus surgery has been proven the therapeutic method of choice in surgical therapy of chronic sinusitis. On the other hand, endonasal sinus surgery may cause severe complications even when performed by a skilled surgeon. This is easily explained by the close vicinity of many functionally important structures to the operative site. CASE REPORTS: Three histories are reported that involve possible complications even in apparently simple cases. Diagnostic and therapeutic consequences are discussed. In a case previously diagnosed histologically as chronic unspecific sinusitis, an endonasal biopsy resulted in endocranial bleeding requiring neurosurgical intervention. Midline granuloma was found to be the correct diagnosis. Another patient was seen with a normal X-ray of the sinuses and solitary polypoid structure in his left nose. Polypectomy was planned and a CT scan was performed, which demonstrated a meningocele. Transfacial surgery was then performed to remove the meningocele. Another patient presented with a traumatic impression of the frontal sinus, and open reposition by transfacial surgery of the frontal and ethmoid sinus was planned. When CT scans revealed an uncovered optic nerve in the sphenoid sinus of the fractured side, we abandoned ethmodectomy and performed reposition of the frontal sinus as the only surgical procedure. RESULTS AND CONCLUSIONS: In this paper, we show typical complications of endonasal sinus surgery and strategies for avoiding them. If any complication occur, prompt treatment is required. Three groups of complications can be defined: perforation of frontobasal dura resulting in cerebrospinal fluid (CSF) fistula, severe bleeding, and orbital or optic nerve injury. When the surgeon discovers an intraoperative complication, possible consequences must be considered immediately to minimize side effects for the patient. A CSF fistula should be closed in the same procedure, and transfacial surgery may be necessary. Hemorrhage resulting from an ethmoidal artery may require frontoorbital surgery and ligation of this vessel. If retrobulbar hemorrhage caused by retraction of an ethmoid artery occurs, immediate intervention is necessary. Usually a transfacial approach, resection of the medial orbital wall and retrobulbar decompression are performed. In some cases lateral canthotomy may be the best way to drain haematoma and decompress the optic nerve. Subsequently, orbital revision and ligation of the retracted artery must be performed. Any delay can result in persistent visual loss. We conclude that the extranasal frontoorbital approach should be part of the residency training program in ENT departments. Any surgeon performing endonasal sinus surgery must be trained in transfacial emergency procedures, which should be part of anatomic preparations in teaching courses, thus avoiding severe damage in case of intraoperative complication.     

Medical personnel and patient skill in the use of metered dose inhalers: a multicentric study. CESEA Group

Gastroesophageal reflux may be responsible for atypical extra-esophageal symptoms, such as chest pain, dyspnea, chronic cough, or hoarseness. Prospective studies of gastroesophageal reflux have indicated reflux as the cause for chronic cough in 10 to 20% of patients. The precise mechanism by which reflux causes cough remains uncertain, although the possibility that the cough is caused by stimulation of the esophageal mucosa receptors rather than aspiration is suggestive from some studies. Prolonged esophageal pH monitoring affords an opportunity to document objective gastroesophageal reflux. Furthermore, pH monitoring gives the opportunity to correlate temporally acid reflux events with the onset of certain symptoms.     

Case report: acute renal vein thrombosis in patients with spinal cord injury and secondary amyloidosis

Chronic spinal cord injury, when complicated by chronic suppurative infections, has replaced chronic tuberculosis as a leading cause of secondary amyloidosis. Renal involvement with secondary amyloidosis is characterized by the presence of nephrotic range proteinuria and an increased incidence of renal vein thrombosis. Two cases of acute renal vein thrombosis associated with secondary amyloidosis in patients with spinal cord injury are presented. In both cases, a past history of extensive decubitus ulcerations and urinary tract infections preceded the development of nephrotic range proteinuria. In case 1, nonoliguric acute renal failure occurred after the development of acute bilateral renal vein thrombosis. The patient declined dialytic therapy and expired with uremia. In case 2, worsening renal function and increased proteinuria resulted after the development of acute unilateral renal vein thrombosis. These cases include the clinical and anatomic findings of acute renal vein thrombosis that occur as a complication of secondary amyloidosis. Acute renal vein thrombosis should be considered whenever an acute change in renal function or increase in proteinuria is noted in this setting.     

Psychometric properties of the National Eye Institute Visual Function Questionnaire (NEI-VFQ). NEI-VFQ Field Test Investigators

OBJECTIVE: To test the reliability and validity of the 51-item Field Test Version of the National Eye Institute Visual Function Questionnaire (NEI-VFQ) across 5 common chronic eye conditions. DESIGN: Prospective observational cohort study of persons with 1 of 5 chronic eye diseases who were scheduled for nonurgent visits in ophthalmology practices or had low vision from any cause, and a reference sample of persons without eye disease. SETTING: Six university-based ophthalmology practices and the National Eye Institute Clinical Center, Bethesda, Md. PATIENTS: Eligible participants had to have 1 of the following eye conditions: age-related cataracts, age-related macular degeneration, diabetic retinopathy, primary open-angle glaucoma, cytomegalovirus retinitis, or low vision from any cause. Each of the 7 sites also enrolled persons in a reference sample. Reference sample participants had no evidence of underlying eye disease but were scheduled for either screening eye examinations or correction of refractive error. All eligible persons had to be aged 21 years or older, English speaking, and cognitively able to give informed consent and participate in a health status interview. MEASUREMENTS AND MAIN RESULTS: To provide the data needed to assess the reliability and validity of the 51-item NEI-VFQ, all subjects completed an interview that consisted of the 51-item NEI-VFQ, the Medical Outcomes Study 36-Item Short-Form Health Survey, and at least 1 measure of vision-targeted functional status. Estimates of internal consistency and test-retest reproducibility indicate that the 51-item NEI-VFQ is reliable. Tests of association with other scales and clinical variables support the construct validity of the survey. CONCLUSIONS: In this cross-sectional study, the 51-item NEI-VFQ seems to be reliable and valid and should be a useful tool for group-level comparisons of vision-targeted, health-related quality of life in clinical research. Additionally, the psychometric properties of the NEI-VFQ were not influenced by the type or severity of the underlying eye disease, suggesting that the measure will provide reproducible and valid data when used across multiple eye conditions.     

Systemic production of interferon-gamma inducing factor (IGIF) versus local IFN-gamma expression involved in the development of Th1 insulitis in NOD mice

Bronchial asthma in childhood is defined as a disease presenting with wheezing, dyspnea and cough on the basis of an inflammatory bronchial hyperreagibility. It is the most common chronic disease in childhood. There are a variety of causes for asthma. Certainly allergy is the most common cause in childhood but also environmental pollution is of importance. Asthmatic attacks, episodes of asthma and asthmatic cough are the most frequent clinical manifestations where as the malignant, hypoxemic asthma crisis is of special importance since its mortality is as high as 0.5-0.8/100,000. Special notice has to be taken on the evaluation of obstructive bronchitis in infancy and childhood which might be very difficult. During the past years, the use of inhalative steroids in the long term treatment has gained increasing importance also in childhood, since it could be demonstrated that side effects of clinical relevance are hardly to be expected.     

Lipoma of the small intestine as a rare cause of intestinal occlusion

Lipoma is a benign tumour of mesenchymal origin which is not frequently localized in the gastroenteric tract; in anatomopathological statistics it is less rare: this is due to the fact that it rarely reaches dimensions which warrant surgical treatment. It is usually either an occasional finding during the course of laparotomy due to other motives or is the cause of complications, as in the present case of intestinal occlusion due to ileocolic invagination, resulting in emergency surgery. As a cause of occlusion tumours of the small bowel are second in terms of incidence to adhesive factors, volvuli and hernias. Invaginations account for 2/3 of small bowel occlusions caused by up to 80% of tumours: the lipoma is the most frequent benign tumour to cause invagination in its submucous polypoid and more or less scissile form. Symptoms are not specific and this causes a delay in diagnosis. Patients are often young subjects with a history of recurrent abdominal colic and sensitivity to anti-spastic drugs so much so that in the past they were diagnosed as "chronic colic" sufferers. Sometimes the only symptom is dyspepsia, or nausea and vomiting, or occasionally abdominal distension with constipation or attacks of diarrhoea. Radiology is not of great value in the diagnosis except for indicating the possible need for emergency surgery. There are no radiological tests, with or without contrast mediums, echography, CAT or MNR which can diagnose this pathology. The decision to operate is usually triggered by the presence of a complication, but perioperative extemporary histological tests are advisable for a correct surgical approach: if the form is scissile, segmentary resection of the small bowel is necessary.(ABSTRACT TRUNCATED AT 250 WORDS)     

Potential role of streptozotocin in enhancing ossification of the posterior longitudinal ligament of the cervical spine in the hereditary spinal hyperostotic mouse (twy/twy)

The differential diagnosis of ascites often leads to confusion and an inability to exclude its multitude of causes in many patients. In this review, we outline the clinical features and laboratory investigations that usually elucidate the cause of ascites for the clinician in a simple and logical manner. Roughly 80-85% of cases of ascites are related to underlying chronic liver disease, but cardiac failure, tuberculosis, malignancy-related ascites and other less common causes should always be considered. Careful evaluation of the patient, including a clinical history, physical examination and diagnostic paracentesis should routinely be performed to determine the cause of ascites. Fluid should be sent for cell count and albumin along with simultaneous determination of serum albumin to determine the serum: ascites albumin gradient. This gradient allows classification of the cause of ascites into portal hypertension-related and nonrelated with a diagnostic accuracy of > or = 97%. The causes of ascites are individually discussed in relationship to their clinical features and to the laboratory investigations that are relevant in each situation.     

Irritable oesophagus syndrome as cause of chronic cough

Case of an infant with chronic cough is reported. The most frequent causes of chronic cough were ruled out. Twenty-four hour oesophageal pH-monitoring showed a close correlation between gastro-oesophageal reflux episodes and cough attacks. The patient was successfully treated with cisapride (0.3 mg/kg t.i.d.). These findings show that irritable oesophagus syndrome can cause chronic cough.     

Clinicopathological study of cases with Mycobacterium szulgai infection

Pulmonary mycobacteriosis is usually caused by Mycobacterium tuberculosis, Mycobacterium avium complex, or Mycobacterium kansasii. There are, however, other slow-growing mycobacteria which can cause pulmonary infection. Mycobacterium szulgai, first reported in 1972, is a scotochromogenic species which can affect human lungs, although human-to-human spread of infection is thought to be unlikely. We have recently treated three cases of middle-aged to elderly persons (45-87 year-old), two of them had underlying diseases (one with intrapulmonary and the other with extrapulmonary). All patients had constitutional symptoms (cough, sputum, dyspnea), and chest roentgenograms demonstrated either cavitation with scattered nodules or peripheral infiltrates predominantly in upper lobes, resembling pulmonary tuberculosis. In two cases, M. szulgai was identified by using DNA-DNA hybridization method. The in vitro susceptibility of M. szulgai to antimycobacterial drugs was better than that of M. avium complex, and it was resistant only to paraaminosalicylate, cycloserine, and partially to isoniazid. Pulmonary disease of three patients were successfully treated with a combination of multiple antimycobacterial agents including rifampin, ethambutol, isoniazid, or streptomycin.     

Hereditary spherocytosis. Studies of erythrocyte enzymes and fetal hemoglobin before and after splenectomy

A survey is given on development, proof and clinical importance of an M-gradient which is to be demarcated in the electrophoresis. A M-gradient refers to an excessive increase of the number of monoclonic immunoglobulins (= paraproteins). As investigation method the electrophoresis on agar or agarose, respectively, is best suited. The immunoelectrophoresis is necessary for the further differentiation into several classes and types as well as for the demarcation of pseudo-M-gradients. The proof of a M-gradient alone does not allow a diagnosis. M-gradients obligatorily appear in the plasmocytoma, in Waldenstroem's macroglobulinaemia and associated neoplasias of the lympho-plasma-cellular tissue. However, M-gradients can also be observed in carcinomas, chronic liver diseases and chronic inflammatory processes as well as in clinically healthy persons in individual cases. The differentiation according to the cause of the M-gradient is possible only then, when the total clinical picture is taken into consideration, in individual cases, however, according to the course of the disease.     

Lithiasic, congenital, choledochal dilatation: problems of diagnosis and therapy

We report a case of a 30-year old female with congenital lithiasic choledochal dilatation which was not diagnosed at the ultrasonographic examination. Congenital biliary dilatation abnormalities are rare and may clinically present with episodic biliary colics or more rarely with recurrent pancreatis. Ultrasound, CT-scanning and ERCP usually make these anatomic alterations evident but in some cases there may be some doubt despite the vast range of radiological techniques available (PTC, Tc99m-Isida scinti-scan). The best results from a diagnostic point of view are obtained from the ERCP that may in fact visualize an anomalous pancreatico-biliary junction, rule out carcinoma, accurately define the cyst dimensions or show the intrahepatic ductal radicals. Furthermore, the extraction of intracystic stones or the treatment of choledochocele through a papillostomy may be performed. However the ERCP may cause traumatic pancreatitis, above all in youngster as was verified in our patient. During surgical exploration, the definitive diagnosis can be achieved via intraoperative cholangiography. We emphasize that in patients with congenital choledochal dilatation, the dilated choledochus should be excised even in young children to avoid the risk of malignancy which may occur also following cyso-duodeno- or cystojejunostomy treatment. In our patient an hepatiocojejunostomy on a Roux-en-Y limb was performed. This single case has been oresented along with a review of the literature to recall such anomalies in differential diagnosis of biliary colics and to stress that the choice treatment is surgical resection.     

Surgical management of soft tissue sarcomas: principles of resection and reconstructive plastic procedures

1. Adequate complete surgical resection with a oncologic radical or wide margin of normal tissue represents the most important measure to prevent a local recurrence. Limited excision with "shelling-out" of the tumor, through its "pseudocapsule" almost invariably means positive microscopic margins. The pathohistologically or macroscopically marginal or intralesional positive resection margins make a salvage surgery necessary. 2. A close safety margin of < 1 cm due to neighboured anatomic structures indicates a high risk of local recurrence and makes an adjuvant radiotherapy mandatory. Plastic-reconstructive surgery should prepare the radiotherapy fields, to avoid cavities or ulcerations. 3. Facts should be stated in the clinical record and the operation report, e.g. the safety margin should be defined by the surgeon and the pathologist; the histopathologic stage and grade are absolutely basic requirements. If necessary, a second histopathologic review should be asked for. 4. Tumor resection and reconstructive oncoplastic measures should correspond individually to the oncologic parameters, to the functional demands and to the age of the patient. 5. Multidisciplinary cooperation in a tumorboard is a precondition for an adequate treatment.