Ultrasonography of the Achilles tendon in hypercholesterolemia

The classical treatment of uretero-ileal anastomotic strictures after Bricker uretero-ileostomy is open surgical revision. Recent progress in endourology has provided a number of alternatives. The success rate of these endoscopic techniques is less than the success rate of the open surgical revision.     

Achilles and peroneal tendon injuries in the athlete. An expert's perspective

Peroneal tendonopathy or injuries are not common but may be troubling to the sports enthusiast. Prompt diagnosis and treatment usually result in complete recovery with conservative measures. Biodynamic orthosis with deep heel cups and a long lateral flange extension often are required for return to activity. MR imaging is helpful in difficult, persistent cases to check for ruptures. Surgery is not commonly performed but if required is usually successful in correcting the pathology. Alternative medicine may improve treatment outcomes. Biomechanical functional analysis and attention to training errors is essential in any lower extremity injury or pathology.     

Comparison of ultrasonography and magnetic resonance in the postoperative monitoring of complete subcutaneous rupture of the Achilles tendon]

The diagnostic accuracy of US and MRI in the subcutaneous rupture of the Achilles tendon has already been assessed. We used both techniques to study the Achilles tendon during the postoperative repair process after surgery according to Bosworth. The results were compared and discussed in relation to clinical recovery. Ten patients with complete subcutaneous rupture of the Achilles tendon were followed-up with physical examination and submitted to US and MR studies 40, 60 and 90 days postoperatively. Eighty patients recovered in the expected time, while 2 took longer. At 90 days, the US findings in 7 patients and the MR findings in 8 patients who recovered in the expected time could be considered normal. US poorly distinguished the tendon from the reinforcement flap because of gross tendon echostructure. The tendon and the reinforcement flap were not distinguishable at MRI because they were uniformly hypointense. Clinical recovery appeared as a hyperechoic structure and a gross fibrillar pattern at US and as a hypointense structure with some small hyperintense areas at MRI. US and MRI were in disagreement in one patient with a postoperative algodystrophic syndrome, where US showed some alterations which were considered false positives because of clinical recovery and negative MR findings. US and MR patterns were considered abnormal in the 2 patients with delayed recovery. US showed persistent hyperechoic areas within the tendon, while the MR signal was of intermediate intensity in the tendon and reinforcement flap. To conclude, we believe that US is an appropriate technique for the postoperative follow-up of complex subcutaneous ruptures of the Achilles tendon. Additional MRI should be performed in all the cases where US findings are in disagreement with clinics.     

Seizure disorders in the dog. 1. Clinical features and differential diagnosis

For differential diagnosis, therapy, and prognosis of seizures in dogs it is recommended to distinguish between two groups of diseases: 1. Epilepsy is diagnosed if seizures occur repeatedly without an active, underlying disorder. Idiopathic epilepsy occurs most commonly. A hereditary component has been demonstrated in several breeds. Symptomatic epilepsy results from previous resolved forebrain disorders, which cause epileptic seizures through scar formation. 2. Seizures are caused by active structural forebrain disease or metabolic-toxic imbalances. Upon initial presentation of the dog, a preliminary classification may be achieved with the seizure history, clinical and neurological examination, and routine laboratory evaluation. The diagnosis of idiopathic epilepsy is based on typical seizure history and exclusion of structural forebrain disease and metabolic-toxic imbalances with special laboratory testing, CSF examination, and brain scanning procedures.     

Insidious rupture of the Achilles tendon after ciprofloxacin-induced tendopathy. A case report

A 64-year-old male patient had two episodes of transient ischemic attack and a cerebral infarction. Cerebral angiography showed 50% stenosis at the junction of left internal carotid artery and 90% stenosis at left mid-cerebral artery (MCA). Coronary angiography showed two vessel disease with arteriosclerotic change and underwent coronary artery bypass grafting. To prevent intraoperative cerebral infarction, we used brain protect solution just before starting ECC, set perfusion flow around 3 l/min/m2, monitored the flow of left MCA using Transcranial Doppler (TCD) and the saturation of left internal jugular vein (SjO2) continuously. PaCO2 was controlled around 45 mmHg. TCD showed good pulsatile flow, and SjO2 was kept over 60%. The patient recovered consciousness 2 hours after operation in the intensive care unit without paresthesia. We thought the number of open-heart cases with cerebrovascular disease increased, and pulsatile low of ECC by intraaortic balloon pumping and the monitoring of SjO2 are useful for the cases.     

Diseases of the Achilles tendon in dogs and cats

Dogs and cats rarely have problems with the Achilles tendon and if so, it usually results from a direct trauma. Prime area for injuries is the insertion on the tuber calcanei or directly proximal. One defers between complete and partial ruptures, acute and chronic injuries as well as displacement of the tendon of the superficial digital flexor muscle. In 38 cases (33 dogs and five cats) the clinical examination, radiology, ultrasonography and therapy are shown. Usually the clinical examination is sufficient for a diagnosis (hyperflexion of the hock and weight-bearing on the plantar surface of the metatarsus). The radiology primarily shows up abnormalities on the calcaneus, mineralisations of the tendon and allows the assessment of implants. Ultrasonography is the diagnostic imaging of choice for judgement of tendon diseases as well as the progress of their healing. Tendon suture is advisable if the rupture is open, fresh and/or complete and in cases of luxation of the superficial digital flexor muscle. Immobilisation of the tarsus in hyperextension seems to be of utmost importance no matter if an operative or conservative therapy is chosen.     

Clinical factors contributing to the differential diagnosis of primary insomnia and insomnia related to mental disorders

OBJECTIVE: Primary insomnia and insomnia related to mental disorders are the two most common DSM-IV insomnia diagnoses, but distinguishing between them is difficult in clinical practice. This analysis was performed to identify clinical factors used by sleep specialists to distinguish primary insomnia from insomnia related to mental disorders. METHOD: Clinicians evaluated 216 patients referred for insomnia at five clinical sites, rated a list of clinical factors judged to contribute to each patient's presentation, and assigned diagnoses. Analysis of variance was performed, with contributing factors as the dependent variable and diagnostic group and clinic location as independent variables. RESULTS: Sleep specialists rated a psychiatric disorder as a stronger factor for insomnia related to mental disorders and rated negative conditioning and sleep hygiene as stronger factors for primary insomnia. However, a psychiatric disorder was rated as a contributing factor for 77% of patients who received a first diagnosis of primary insomnia. CONCLUSIONS: While neither sleep hygiene nor negative conditioning is a diagnostic criterion in DSM-IV, these results support the face validity of these clinical factors distinguishing between primary insomnia and insomnia related to mental disorders. The use of a psychiatric disorder as an inclusion criterion for insomnia related to mental disorders and an exclusion criterion for primary insomnia reinforces a categorical distinction between the two diagnoses, but the contribution of psychiatric symptoms in primary insomnia appears to be a clinically relevant one. These findings suggest the need for studies on the validity of negative conditioning and sleep hygiene in the etiology of primary insomnia, as well as on the significance of psychiatric disorders, especially depression, in primary insomnia.     

Diagnosis and differential diagnosis of sleep disorders in children

Sleep disorders in children are very common and their impact on emotional and cognitive functions is considerable. Clinical work necessitates an interdisciplinary access to the subject because the scope of sleep medicine is related to various medical disciplines (e.g. paediatric neurology, pulmology and child psychiatry). Although many sleep problems are seen in both children and adults diagnoses, symptoms and pathogenetic factors are quite different in the two groups. In childhood especially parent-child interactional factors and developmental aspects of the sleep architecture and the sleep-wake cycle have to be taken into account leading to different diagnostic and therapeutic approaches. In this article we focus on important developmental aspects of childrens' sleep problems. Their relationship to neurologic, paediatric and psychiatric diseases is demonstrated and finally clear indications to diagnostic procedures, especially polysomnography, are given.     

Early differential diagnosis of congenital and birth injuries of the brain

The presented paper is a comparative study of clinico-immunological data with neuro-roentgen contrast methods (pneumoencephalography) in 156 newborns. The obtained data with a highly significant result permit to claim that the neuroimmune reactions up to the 7th day of life and even later, may reflect pathological changes of the brain in the newborn. Quite possibly they may be actively involved in the pathological process not only in the prenatal, but also in some cases in the postnatal ontogenesis.     

Oculomotor testing in the differential diagnosis of degenerative ataxic disorders

BACKGROUND: Oculomotor abnormalities have been reported in patients with degenerative ataxic disorders. OBJECTIVE: To assess the diagnostic sensitivity and specificity of oculomotor deficits in patients with Friedreich ataxia (FA), cerebellar atrophy (CA), and olivopontocerebellar atrophy (OPCA). SETTING: Neurology clinic at a university hospital in Lübeck, Germany. PATIENTS: Seven patients with FA, 9 with CA, and 10 with OPCA were studied. These patients were selected from an ongoing follow-up study. MAIN OUTCOME MEASURES: Eye movements were recorded by electro-oculography; an extensive battery of quantitative tests was used. RESULTS: A proven CAG repeat expansion on chromosome 6 or 14 was significantly associated with reduced saccadic eye velocity and vertical gaze palsy (P<.001, Mann-Whitney U test). All 6 patients with OPCA and slow saccades had an autosomal-dominant inheritance; 4 of them were proved to have spinocerebellar atrophy type 1. In 9 of these patients (4 with FA, 1 with CA, and 4 with OPCA), the genetic defect could not be identified. Saccadic dysmetria, impairment of smooth pursuit and optokinetic nystagmus, deficient suppression of the vestibulo-ocular reflex by either visual or otolith input, and pathological nystagmus were attributed to degenerative lesions in different parts of the cerebellum. However, these symptoms failed to clearly distinguish between the different groups of patients, whereas decreased vestibulo-ocular reflex gain, slow saccades, and vertical gaze palsy pointed to an extracerebellar manifestation of the degenerative disease, occurring only in patients with OPCA and FA. CONCLUSIONS: In this prospective study, oculomotor disturbances were mainly related to cerebellar dysfunction. Only a few of them were caused by extracerebellar manifestations of the disease, such as slowing of saccades, which was characteristic for patients with OPCA of autosomal-dominant inheritance.     

The usefulness of Doppler echocardiography in the preoperative assessment of valvulopathies. A comparison with the hemodynamic and surgical findings

The Doppler echocardiography and cardiac catheterization studies of all patients who underwent valvular surgery in a three-year period were reviewed to assess the correlation between the estimated severity of valvular disease by both methods. Two-hundred and thirty-five patients (group I: 140 male, age 58 +/- 12; 95 female, age 60 +/- 13) underwent both studies within 6 months. There was agreement on estimation of severity of valve lesions in 140 of 162 patients with aortic valve disease (93% of stenosis, 82% of regurgitations and 79% of mixed lesions), in 58 of 80 patients with mitral valve disease (83% of stenosis, 76% of regurgitations and 33% of mixed lesions) and in 10 of 16 patients with prosthetic valve disfunction. The correlation between both methods was significantly lower in mixed mitral lesions than in the remaining native valve lesions (p < 0.05). Significant disagreement occurred in 4 cases of aortic valve disease, four of mitral valve disease and five of prosthetic disfunction. When disagreement was present, Doppler often underestimated the severity of the disease. Disagreement was more frequent in patients with combined aortic and mitral disease. According to the surgical conclusions cardiac catheterization provided a diagnostic profit in the assessment of the disease severity in 8, 11 and 22% of cases of aortic and mitral valve disease and prosthetic valve disfunction, respectively. Coronary artery disease was present in 19% of patients who underwent coronary arteriography. One-hundred and two patients (group II: 44 m, 48 +/- 15; 58 f, 53 +/- 11) underwent surgery without previous cardiac catheterization.(ABSTRACT TRUNCATED AT 250 WORDS)     

Endomyocardial biopsy--helpful in differential diagnosis between myocarditis and dilated cardiomyopathy. A case report

OBJECTIVES: Inadequate prenatal care is thought to be a major modifiable risk factor for preterm birth, the leading cause of neonatal mortality. To improve high-risk women's financial access to prenatal care, the U.S. Medicaid program underwent major expansions during the 1980s. We evaluated these expansions over the nine-year period 1983 to 1991 in Tennessee to determine their effects on Medicaid enrollment, use of prenatal care, and preterm birth. METHODS: We used linked birth certificates, Medicaid data, and U.S. Census files to identify 610,056 singleton births to African-American or Caucasian women in Tennessee whose last menstrual period was between 1983 and 1991. These were classified by maternal characteristics to identify groups with the greatest postexpansion increases in Medicaid enrollment, which should have benefited most from the policy changes. Study outcomes were Medicaid enrollment by delivery, enrollment in the first trimester, inadequate prenatal care (modified Kessner index), and preterm (< 37 weeks) birth. We calculated the changes (delta expressed as births per 100) between 1983 and 1991 in percentages of births with each of these outcomes. RESULTS: The expansions led to pronounced increases in maternal Medicaid enrollment by delivery (21% of births in 1983 to 51% by 1991) and in the first trimester (from 10% to 37%). Married women with < 12 years of education, < 25 years of age, and < $12,500 mean neighborhood incomes (group 1) had the greatest increase, where enrollment and first-trimester enrollment increased from 24% to 86% and 7% to 68%, respectively. In group 1, the percentages of births with inadequate maternal use of prenatal care decreased substantially, from 12.8% in 1983 to 6.4% in 1991, a reduction of 6.4 births per 100 (95% confidence intervals [CI] = -7.6, -5.3). However, the preterm birth rate did not decrease (9.1% in 1983, 9.4% in 1991, change of 0.3[-0.7 to 1.2] births per 100). For other births, there were lesser increases in Medicaid enrollment, correspondingly lesser decreases in inadequate use of prenatal care, but no reductions in preterm birth rates. CONCLUSIONS: In Tennessee, the Medicaid expansions materially increased enrollment and use of prenatal care among high-risk women, but did not reduce the likelihood of preterm birth.     

Outcomes of disabling cervical spine disorders in compensation injuries. A prospective comparison to tertiary rehabilitation response for chronic lumbar spinal disorders

BACKGROUND: Genotyping based on short tandem repeat (STR) regions is widely used in human identification and parentage testing, in gene mapping studies, and as an approach to studies on the etiopathogenesis and diagnosis of hereditary diseases. We wished to study a new analytical approach that uses capillary electrophoresis and multicolor fluorescence in place of slab gel electrophoresis. METHODS: We evaluated the efficiency for parentage and forensic purposes of the AmpFLSTR Profiler PlusTM typing kit that is used with the ABI Prism 310 Genetic Analyzer (System-2 STR), and that of a widely used panel of nine STRs analyzed with conventional slab-gel electrophoresis followed by radioactive detection (System-1 STR). System-2 STR, based on automated capillary electrophoresis and automated sizing of the alleles by Genotyper 2.0 software, was used to determine the allele frequency of the nine loci in 157 Caucasian subjects from southern Italy. On the basis of the data obtained, we submitted 40 trios to parentage testing. RESULTS: A higher median probability of paternity attribution and power of exclusion were obtained with System-2 STR vs System-1 STR: respectively, 99.99% and 99.95% (P <0.05) for attribution; and five and four excluding loci (P <0.05) for exclusion. The most informative and highly discriminating loci were D18S51, D21S11, and FGA. The combined probability of matching-by-chance for all nine STRs was 1.36 x 10(-12) for System-2 compared with 1.11 x 10(-7) obtained with the other system. The internal standard and allelic ladder of the System-2 STR facilitated accurate and precise genotyping; furthermore, System-2 STR and was faster than the conventional System-1 STR. CONCLUSIONS: The System-2 STR allows rapid testing with higher probabilities of attribution and a higher power of exclusion than with the comparison method with slab-gel electrophoresis.     

Psychoneuroimmunology and its relationship to the differential diagnosis of temporomandibular disorders

Psychoneuroimmunology (PNI) is a field of medicine which joins immunology and neurobiology. It focuses on the relationship of stress upon the hypothalamic-adrenal-pituitary (HPA) axis. Depletion of hormones and neurotransmitters within the HPA-axis, as a result of stress, can lead to a multitude of diseases and disorders. Therefore, it is necessary for the dentist to be familiar with PNI and the HPA-axis in order to make an accurate diagnosis of TMD.     

Sonography of inflammatory bowel disease: findings and value in differential diagnosis

OBJECTIVE: Inflammatory bowel diseases produce segmental or diffuse mural thickening of the intestine that can be detected and evaluated by using sonography. The purpose of this study was to evaluate the sonographic findings and determine their diagnostic value in patients with inflammatory bowel diseases. MATERIALS AND METHODS: We reviewed sonograms of 81 patients with inflammatory bowel diseases. The findings were compared with those of barium study, colonoscopy, and surgery. Forty-five patients had tuberculous enterocolitis, 13 had ulcerative colitis, eight had Crohn's disease, five had ischemic colitis, two had Beh?et's syndrome, and eight had unspecified colitis. Diagnosis was based on surgical and pathologic findings in 23; results of barium study and endoscopic biopsy in 20; and results of barium study, colonoscopic findings, and clinical findings in 38. RESULTS: Seventy-two patients (89%) had sonograms that showed segmental or diffuse mural thickening and a paucity of luminal content in the involved bowel. Involved areas were the ileocecal region in the cases of tuberculous enterocolitis and Beh?et's syndrome, the left side of the colon in ulcerative colitis, and the colon and terminal part of the ileum in Crohn's disease. In ischemic colitis, the distribution of involved bowel was nonspecific. Sonographic findings correlated well with the findings of barium enema or colonoscopy in terms of the involved segments of the bowel. Mesenteric lymphadenitis, omental thickening, and ascites were frequently observed in cases of tuberculous enterocolitis. CONCLUSION: Sonographic evidence of mural thickening of the bowel with a paucity of luminal content may be helpful in the detection of inflammatory bowel diseases. However, the findings are nonspecific, and the differential diagnosis must be related to the specific segment of the bowel involved.     

Value of Doppler color ultrasonography in diagnosis of arterial occlusive disease of the lower extremity. A direct comparison with percutaneous angiography

A Direct Comparison with Percutaneous Angiography: AIM: To compare colour-coded Doppler sonography (CCDS) with conventional angiography in severe occlusive vascular disease of the lower limb. METHODS: In 55 patients 1141 vessel segments were evaluated, 700 of them with atheromatous plaques, 270 with stenoses, 208 with occlusions and 6 with aneurysms. RESULTS: Deeper-seated vessels such as the abdominal aorta, the pelvic arteries, the superficial femoral artery at the level of the adductor canal and parts of the lower leg arteries are less accessible for direct CCDS. Many pathological changes however can be diagnosed indirectly by changes in the spectral wave form distal to the lesion. In superficial vascular segments (the common femoral artery, the profunda femoris artery, the superficial femoral artery above the adductor canal and the popliteal artery) image quality was excellent, more pathological changes were found, and the degree of stenosis was better estimated in comparison to angiography. CONCLUSION: The value of CCDS in patients with intermittent claudication is limited to those who have been examined with angiography e.g. before angioplasty, to follow-up examinations after vascular dilatation or surgery and to supplementary visualisation after angiography especially in readily accessible (superficial) vascular segments.