Lymphoscintigraphy in chyluria, chyloperitoneum and chylothorax

Lymphoscintigraphy allows functional assessment of lymphatic transport and depiction of regional lymph nodes, is fast and nontraumatic and has no known side effects. We retrospectively analyzed lymphoscintigraphic studies to determine their efficacy in the investigation of chyluria, chyloperitoneum and chylothorax. METHODS: Twenty-one whole-body lymphoscintigrams using 99mTc-antimony sulfide colloid or dextran were acquired in 18 patients with chyluria, chyloperitoneum and/or chylothorax. The images were reviewed to assess the rate of tracer transport and number, size and distribution of lymph vessels and nodes as well as the presence of collateral, fistula or lymph reflux. RESULTS: Lymphoscintigraphy was normal (5 of 11 patients) or showed lymphatic obstruction (6 of 11 patients) in chyluria associated with filariasis. Lymphatic obstruction was demonstrated in chyloperitoneum and/or chylothorax associated with liver cirrhosis (2 patients), postoperative (1 patient) or congenital (1 patient) lymphatic dysplasia, inferior vena cava obstruction (1 patient) and nephrotic syndrome (1 patient). Enhanced lymph flow was seen in systemic lupus erythematosus (1 patient). Follow-up lymphoscintigrams showed patency of lymphovenous anastomosis (1 patient), improvement (1 patient) or no change (1 patient) in lymphatic drainage after treatment. CONCLUSION: Lymphoscintigraphy can demonstrate abnormal lymphatic drainage in chyluria, chyloperitoneum and chylothorax. It is useful for selecting patients for surgery and assessing the effect of treatment.     

Diagnosis and therapy of onychomycoses

Given the four different types of onychomycosis, a large number of differential diagnoses have to be considered. It is therefore imperative that prior to treatment a careful diagnostic evaluation be taken. The simplest methods are the microscopic native (unstained) slide and culture, while more complicated methods are histology, immunofluorescence histology and flow cytometry. For local treatment, antimycotic nail varnishes and urea-containing antimycotic ointments are available, as well as itraconazole, terbinafine and, in the near future, fluconazole, for internal administration.     

Diagnosis and therapy of hoarseness

A patient consulting his physician because of hoarseness often suffers from viral laryngitis. This infectious disease usually heals within one or two weeks. If the hoarseness persists for more than three weeks, the patient should be examined by laryngoscopy to exclude a laryngeal cancer. The differential diagnosis includes other organic or functional lesions. Voice therapy is the treatment of choice for functional voice disturbances and for disorders of pubertal mutation, which very rarely are due to hormonal changes. Organic lesions are usually treated by surgery.     

Diagnosis and therapy of constipation

Prevalence of chronic constipation is around 3% in youth, 8% in middle age, and 20% in the elderly, respectively. There are three etiologic groups: 1. Diet poor in fibre. Most constipated persons, however, do not eat less fibre than controls. 2. Organic diseases accompanied by constipation such as autonomous neuropathies (e.g. in diabetes), endocrine disorders, and neurologic diseases (e.g. Parkinsons disease). 3. Functional outlet obstruction. This may be due to disturbed sphincter function, internal rectal prolapse, or rectocele. The basic treatment of all forms of constipation consists in a diet rich in fibre. In selected cases of functional outlet obstruction, surgery may be successful. Otherwise, treatment with laxatives is justified.     

Diagnosis and therapy of diarrhea

Diarrhea is still one of the most frequent causes of death and poses many diagnostic and therapeutic problems. Whereas the etiology of acute diarrhea is mainly infectious, the cause of chronic diarrhea is much more multifarious and thus more difficult to diagnose. The etiology of acute diarrhea as well as the sense and nonsense of diagnostic procedures and therapeutic possibilities are discussed. A rational and practical concept for evaluation of chronic diarrhea is presented.     

Diagnosis and therapy of hyperandrogenism

Diagnostic categories in hyperandrogenism include polycystic ovary syndrome (PCOS) and its variants, adrenal and ovarian steroidogenic enzyme deficiencies, adrenal and ovarian androgen secreting tumours and other endocrine disorders such as hyperprolactinaemia, Cushing syndrome and acromegaly. About 95% of hyperandrogenic women will have PCOS. Endometrial hyperplasia can be prevented in hyperandrogenic, anovulatory women by the oral contraceptive pill or progestins. Hirsutism is best treated by a combination of the oral contraceptive pill and an anti-androgen. The first line of therapy for ovulation induction is clomiphene citrate, with human menopausal gonadotrophins (hMG) or laparoscopic ovulation induction reserved for clomiphene failures. hMG together with gonadotrophin-releasing hormone agonist may decrease the risk of spontaneous abortion following ovulation induction in PCOS. Weight loss should be vigorously encouraged to ameliorate the metabolic consequences of PCOS.     

Diagnosis and therapy of kidney traumas

Argatroban, (2R,4R)-4-methyl-1-(N2 [(3-methyl-1,2,3,4-tetrahydro-8-quinolinyl)-sulfonyl]-L-arginyl)-2-pi peridinecarboxylic acid, a selective and competitive thrombin inhibitor, was examined for effectiveness in three different experimental models of cerebral thrombosis in rats, namely, the four-vessel occlusion model, the middle cerebral artery occlusion model, and the distal middle cerebral artery occlusion model. Argatroban was demonstrated to be effective in these experimental models of thrombosis. Among these models, the distal middle cerebral artery occlusion model was the most similar to clinical cerebral thrombosis with respect to restriction of the infarction to the cerebral cortex and the accompanying stable neurologic deficits. In this model, the thrombus was generated at the Y-shaped bifurcation of the middle cerebral artery by green light irradiation through a cranial window after administration of rose bengal. Argatroban given after thrombus formation by intraperitoneal implantation of an osmotic pressure pump was shown to reduce infarct size and neurologic deficits on day 3 and microthrombi generation on day 1, and to raise the regional cerebral blood flow on day 1, at a plasma level of 0.2 to 0.6 microM supporting its clinical usefulness in the treatment of acute-phase cerebral thrombosis. Argatroban was considered to exert its effects by salvaging neuronal cells in the ischemic penumbra and suppressing extension of the infarction into the penumbra by keeping blood vessels patent, mainly through the inhibition of microthrombogenesis.     

Diagnosis and therapy of malignant lymphedema

In addition to the typical clinical symptoms, the diagnosis "malignant lymphedema" also requires the confirmation of a tumor or a metastasis obstructing lymph flow. With the standard physical treatment of edema described by Asdonk successful clinical management of malignant lymphedema is also possible. The sole contraindication of manual lymph drainage is, we believe, locoregional tumor recurrence, which can be completely eliminated by the immediate initiation of radical tumor treatment. The tumor recurrence is the result not of falsely indicated manual lymph drainage, but of inadequate primary treatment that leaves behind residual tumor tissue, the early detection of which still remains an unresolved problem. Manual lymph drainage is indispensable for improving the quality of life of tumor patients with lymphedema.     

Diagnosis and therapy of fecal incontinence

Fecal incontinence is not a diagnosis, but a symptom which can have multiple causes. The aim of any therapy should be to treat the underlying disorder. This requires a detailed diagnostic procedure in each patient. If no underlying disorder can be found, therapy becomes symptom oriented. Besides drug treatment anal biofeedback training is the most important form of medical therapy. Except for special situations surgery is indicated only if medical therapy has failed.     

Diagnosis and therapy of chronic polyarthritis

Rheumatoid arthritis (RA) is the most frequent inflammatory joint disease, and it affects about 1% of the population. The onset of arthritis is rarely acute; it is subacute and usually progresses slowly. The clinical picture of RA is variable: mild to very aggressive and destructive courses, sometimes accompanied by organ involvement, leading to severe functional impairment and early disability can be observed. RA is diagnosed according to the ACR criteria published in 1958 and modified in 1988. The appearance of a palpable joint swelling or effusion is obligatory for the clinical diagnosis of arthritis. In RA, typically involvement of the joint of the hands and feet can be seen. Laboratory parameters play an important role as both diagnostic and prognostic tools. Besides clinical features and laboratory parameters, imaging techniques provide another cornerstone in the diagnosis of RA. Until now plain X-rays, which primarily visualize osseous changes, are the most important technique in daily practice, whereas magnetic resonance imaging and ultrasound may provide information about soft tissue changes in an earlier stage of disease. The main differential diagnoses of RA to be considered are the seronegative spondylarthropathies (psoriatic arthritis, arthritides accompanying inflammatory bowel diseases, Reiter's syndrome, and spondylitis ankylosans with peripheral arthritis), Parvovirus-induced arthritis, crystal-induced arthritides and septic arthritis. Early diagnosis and therapeutic intervention seem to be of great prognostic importance. In several independently performed investigations a higher mortality was found in RA patients than in the normal population. Drug therapy of RA consists of nonsteroidal antirheumatic drugs (NSAIDs), corticosteroids and disease-modifying drugs (DMARDs). When the functional and radiological parameters were assessed, the DMARDs were found to have a disease modifying and in rare cases a remission-inducing property. Moreover, tolerance these to drugs is limited. Newer therapeutic trials have employed substances like Tenidap, Leflunomid, bacterial extracts, antibiotics and biological subcomes (e.g., monoclonal antibodies against cytokines, fusion proteins for soluble cytokinereceptors). Some promising results of these investigations need confirmation in larger patient populations, but some new perspectives for a more efficacious treatment of RA can be expected.     

Diagnosis and therapy of pancreas divisum

Pancreas divisum patients make up a small but problematic portion of ERCP cases. Minor papilla cannulation techniques have been improved. Recurrent pancreatitis patients generally benefit from minor papilla therapy. Methods to select patients who are likely to respond to invasive therapy need refinement. Clinicians and endoscopists are strongly encouraged to be cautious and conservative with this patient group until stronger data indicate optimal management schemes.     

Diagnosis and therapy of antiphospholipid antibody syndrome

PURPOSE: To report alterations of electrophysiologic tests, including the multifocal electroretinogram, in a case of acute zonal occult outer retinopathy. METHOD: We recorded photopic, scotopic, and single-flash electroretinograms and a multifocal electroretinogram in a 47-year-old woman with acute zonal occult outer retinopathy in the right eye. RESULTS: Her visual acuity was 20/20 in the right eye throughout the follow-up period. The electroretinograms indicated retinal impairment of the right eye, predominantly in the cones. The multifocal electroretinogram showed reduced responses corresponding to the visual field defect of the static perimetry. CONCLUSIONS: In acute zonal occult outer retinopathy, impairment of the retinal area results in a visual field defect. The multifocal electroretinogram can be useful in determining the location of the defect.