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PubMed2005

[Minimally-invasive management of common bile duct stones].

Common bile duct stones may present a health hazard for our patients. Nevertheless, since the implementation of laparoscopic cholecystectomy optimal diagnostic and therapeutic algorithm are not yet defined. Symptomatic calculi can be assumed on the basis of pathological laboratory values or diagnosed by means of ultrasound, Intraoperative Cholangiography (IOC) or Magnetic-Resonance-Cholangio-Tomography (MRCT). For therapy of common bile duct stones endoscopic and laparoscopic minimally-invasive strategies are available. As any type of management may show some benefit, it is not yet evident which policy we should prefer. Specialists do not agree on the necessity of therapy in asymptomatic patients with common bile duct calculi at all. This article shows a current state of the opinion and art and tends to highlight trends and future perspectives.

Cholangiography↗
PubMed2000

Diagnosis of allergic bronchopulmonary aspergillosis (ABPA) in cystic fibrosis.

BACKGROUND: The diagnosis of allergic bronchopulmonary aspergillosis (ABPA) in cystic fibrosis (CF) patients may be difficult to establish because ABPA shares many characteristics with coexisting atopy or other lung infections in these patients. This study aimed to evaluate the sensitivity and specificity of various paraclinical parameters in the diagnosis of ABPA in patients with CF. METHODS: Accumulated data from a 5-year period in 238 CF patients were used to divide patients into two groups designated the ABPA group (n=26) and the non-ABPA group (n = 35). Patients in both groups were colonized with Aspergillus fumigatus (Af.), but only the ABPA group consistently demonstrated specific IgE antibodies and specific precipitins. Patients without A. fumigatus colonization were not assigned to either of these groups (n = 177). By this selection as the true diagnosis, 10 patients were selected from the ABPA group and 10 patients from the non-ABPA group. RESULTS: The groups were comparable as to age, sex, lung function (P=0.6), and presence of chronic Pseudomonas aeruginosa infection (P>0.1). No significant difference between the groups in unspecific atopic parameters such as eosinophil count (P=0.9) or eosinophil cationic protein (ECP) in sputum, plasma, or serum (P=0.9, P=0.59, and P = 0.9, respectively) was demonstrated. Total IgE was significantly higher in the ABPA group (P<0.01). The groups were comparable in skin prick test (SPT) positivity to a standard panel of aeroallergens (pollen, dander, molds, and mites) (P>0.2). Statistically significantly higher levels in the ABPA group were demonstrated in specific IgE to Af. (P < 0.05), SPT positivity to Af. (P < 0.02), and Af. precipitins (P < 0.05). Histamine release (HR) to Af. tended to be higher (P=0.075) in the ABPA group. Specific IgE to Af. was determined by Magic Lite (ML), CAP, and Maxisorp (in-house RAST). The CAP level was one to two classes higher than the ML level; however, the results were comparable (r=0.66, P<0.005). IgE to Af. measured by CAP was the test which offered the highest positive predictive value (PPV) and negative predictive value (NPV). Optimal diagnostic cutoff levels for the diagnosis of ABPA were determined: class 2 for HR to Af., 200 kIU/l for total IgE, and 3.5 (titer) for precipitating antibodies to Af., and class 2 for IgE to Af. (by CAP System). CONCLUSIONS: Unspecific atopy markers were of limited value for the diagnosis of ABPA. Patients with ABPA do not seem to be more atopic to other aeroallergens than non-ABPA patients. The most valid parameters for the diagnosis of ABPA in CF are SPT to Af., IgE to Af. in combination with precipitating antibodies to Af., and/or total IgE.

Adolescent↗
PubMed2005

[Skin protection and skin disease prevention courses for secondary prevention in health care workers: first results after two years of implementation].

BACKGROUND: Healthcare workers have an increased risk of occupational dermatoses. In January 2002, the Department of Social Medicine, Occupational and Environmental Dermatology of the University of Heidelberg started organizing special prevention courses for this group of employees in cooperation with the Accident Prevention & Insurance Association for Health Care Workers (BGW). The major aims are to improve individual skin protection and skin care habits, as well as to optimize diagnostic procedures and therapy. PATIENTS AND METHODS: The two-day course has up to 14 participants. Teaching units mainly focus on skin structure and function, general aspects of occupational skin diseases, general information concerning skin protection and practical exercises emphasizing the correct use of skin cleansing and skin protection products. Additionally, every participant undergoes a dermatological examination including a detailed history and skin inspection. Individual skin protection strategies are developed, and the participants are provided with the opportunity to ask the dermatologist questions in confidence. RESULTS: Most of the 355 participants have been female (87.3%) with a mean age of 36.9 years. 95% had hand eczema, predominantly dyshidrotic morphology. In many cases, there was a mixture of atopic, irritant and allergic contact dermatitis but irritant contact dermatitis was most common (43%). Atopy was present in 68% of the patients. The participants rated the course as good to excellent. Other benefits are the exchange of experience between patients working in the same or similar occupations and transfer of the new knowledge to colleagues, family and friends. CONCLUSIONS: Examinations and advisory services in occupational dermatology are still fragmentary. Skin barrier creams and moisturizers are not sufficiently utilized in daily practice. In the future, similar courses should be offered for employees in other professions with an increased risk of occupational skin diseases.

Adult↗
PubMed2002

Renal and ureteric trauma: diagnosis and management in Poland.

OBJECTIVE: To analyse retrospectively kidney and ureteric injuries (the former often associated with multiple-organ trauma) and thus optimize diagnostic and treatment methods. PATIENTS AND METHODS: The records and details of kidney and ureteric injures treated between 1995 and 1999 in 61 urological departments in Poland were analysed. RESULTS: In all, 887 kidney injuries were analysed; blunt trauma comprised 97%, with most injuries classified as renal contusion and minor parenchymal damage (687 cases). Intravenous urography was used in 80% of the patients and computed tomography in only 20%. In all, 234 patients (26%) underwent surgery; nephrectomy was the most common surgical treatment, in 170 patients (73% of those undergoing surgery). Complications occurred in 9% of patients after conservative treatment and in 5% after surgery. Of the 452 ureteric injuries, 340 (75%) were iatrogenic, 81 (18%) blunt injuries and 31 (7%) open injuries. Of the iatrogenic injuries 73% occurred during gynaecological procedures, 14% in general surgery and 14% in urological procedures. The most frequent diagnostic method was intravenous urography (244 cases), with retrograde pyelography (98) and ureteric catheterization in 125. The diagnosis was established immediately during surgery in 104 patients. The most frequent surgical treatment was uretero-neocystostomy (213, 47%), the others being a Boari flap (113, 25%), end-to-end anastomosis (92, 20%), reconstruction with an ileal loop (30, 7%) and autotransplantation (four, 1%). CONCLUSION: In Poland, patients with blunt kidney injuries often undergo surgery, with nephrectomy the most frequent procedure. Computed tomography with the intravenous administration of contrast medium should be considered the diagnostic method of choice for kidney injures. Catheterization of the ureters before surgery and an indigocarmine intravenous infusion (to stain the urine) when a ureteric injury is suspected may reduce the rate of iatrogenic injury and improve the rate of intraoperative diagnosis. We suggest catheterizing the ureters in any doubtful case to avoid injury, because prevention is better than treatment.

Humans↗
PubMed1976

Cranial computerized tomography in the diagnosis of brain disorders in infants and children.

Cranial computerized tomography (CCT) has opened new dimensions in the diagnosis of neuropediatric disorders. The results of this new method are comparable to gross neuropathology. Thereby it is often possible to avoid further invasive neuroradiological investigations. This is especially true of pneumoencephalography which, according to the present state of CCT, is no longer indicated. Optimal diagnostic results can be achieved only if the patients is cooperative and does not move his head during the scanning procedure. Therefore in infants general anaesthesia is necessary. Sedation alone has proved to be not sufficient. The numerous new findings gained by CCT cover nearly all types of intracranial lesions. First of all the direct visualization of brain tumours in their relations to the surrounding structures, the surprising findings in inflammatory diseases of the brain, and the impressive demonstration of brain anomalies make CCT superior to all conventional neuroradiological investigations. Only for planning a surgical intervention and in vascular disorders angiography remains irreplacable.

Adolescent↗
PubMed1975

[Radiculo-tomography for lumbosacral myelography (author's transl)].

The use of tomography can increase the value of lumbosacral myelography in certain circumstances. Post mortem studies have resulted in standardisation of the examination, which will combine optimal diagnostic information with the least amount of effort and with an acceptable amount of stress on the patient. 110 tomographic examinations were performed amongst 680 lumbosacral myelograms (Dimer X). On the basis of this experience, the value of this procedure is illustrated from various points of view and its indications are discussed.

Humans↗
PubMed1976

[Cervical myelography with water-soluble contrast medium (Metrizamide). Technique and preliminary results (author's transl)].

Use of a water-soluble contrast medium for cervical spinal diagnosis has become possible with the introduction of Metrizamide (Amipaqque). Injection of contrast at the C.1/2 level by a lateral approach results in excellent visualisation of the cervical theca with previously unobtainable detail. This technique, which is so far not well known, allows a rapid examination and when used with the new, well tolerated contrast media provides optimal diagnostic results.

Cervical Vertebrae↗
PubMed2001

Thromboembolism occurrence and diagnosis in the medical intensive care unit.

Venous thromboembolism (VTE) represents an unrelenting and formidable challenge in the critical care setting even for the most experienced clinician. The morbidity and mortality attributed to untreated VTE have been substantiated by increasing series of epidemiologic and postmortem studies. As a larger group of the general population grows older, with increasing requirements for critical care services, challenges for the intensivist in the diagnosis and management of VTE are expected to grow. Moreover, despite the tremendous development of many critical care technologies, complexities of medical conditions commonly encountered in the critically ill have detracted from suspicion of VTE and made prompt recognition difficult. The approach to diagnosis of VTE should optimize diagnostic yield and outcomes with responsible use of resources. Key to an appropriate approach of VTE diagnosis in the intensive care unit is an understanding of the predisposing risk factors--pretest probability and the strengths and weaknesses of available diagnostic tools. Rational use of ultrasound, impedance plethysmography, computed tomography (CT), echocardiography, contrast venography, angiography, and D-dimer assays have provided the clinicians with a more substantial armamentarium, albeit incomplete, to facilitate diagnosis of VTE. The best use of these diagnostic tests often are dependent on local availability and expertise as part of a multidisciplinary team. With application of sound clinical principles in identifying select patients at risk and disciplined use of diagnostic technologies using simple algorithms, improvements in the diagnosis and management of VTE in the intensive care unit may be expected.

Decision Making, Computer-Assisted↗
PubMed2003

High-resolution computed tomography in the diagnosis of diffuse lung disease: a clinical perspective.

High-resolution computed tomography (HRCT) has a central role in the routine detection and diagnosis of individual diffuse lung diseases. The widespread use of HRCT has been stimulated by numerous published series, which have evaluated the accuracy of HRCT in cohorts of patients. However, these series have not simulated the integration of HRCT into clinical diagnosis, and this has led to difficulties in achieving the optimal diagnostic use of HRCT in routine practice. This article summarizes the problems facing the clinician in applying HRCT series to diagnosis in individual patients. The flaws in published series are discussed and the importance of integrating HRCT data with baseline clinical information and, in selected cases, histopathologic findings is highlighted.

Journal Article↗
PubMed2006

[Depression, a widespread disease. Epidemiology, care situation, diagnosis, therapy and prevention].

According to a WHO study depressive disorders are the worldwide leading cause for life years lived with disability. Beside the direct costs of care, enormous indirect costs are caused by disablement and permanent incapacity to work. Furthermore, depressive disorders are often accompanied by suicidal behaviour, and they increase the mortality rate due to cardiovascular disorders. Despite their outstanding importance, there is a huge need to optimize diagnostic and therapeutic procedures in primary care, because depression is often masked by somatic symptoms. To achieve a correct diagnosis, the medical practitioner must actively explore the core criteria of depressed mood, diminished interest and pleasure, as well as fatigue and loss of energy. Improvement of early recognition and treatment of depressive patients is thus the main objective of modern awareness programs such as the "German Alliance against Depression", which was established in the framework of the German Research Network on Depression and Suicidality.

Cardiovascular Diseases↗
PubMed1998

[Subjective experiences of patients with acute neuroleptic-induced akathisia].

Neuroleptic-induced akathisia is a clinically important neuropsychiatric syndrome with mainly subjectively experienced psychic symptoms on the one hand and well-observable motor signs on the other. There is no general consensus of opinion on the relative importance of these two aspects for diagnosing akathisia. Hence, differential diagnosis is difficult and in the absence of a biological marker it depends crucially on clinical judgement. Systematic investigation of 27 in-patients via a semistructural interview, a self-assessment scale (20 in-patients) and established akathisia rating scales (Hillside, Barnes, Prince Henry Hospital and Chouinard) revealed four characteristics of subjective experience in acute neuroleptic-induced akathisia: 1. perception of a foreign but nevertheless inner compulsion to move; 2. lack of control over motor behaviour; 3. feeling of inhibition of purposeful actions and 4. subjectively close or inseparable relationship between inner restlessness and restless movements. These features are strongly interrelated and correlate with severity of akathisia. They could be useful in differentiating akathisia from other states of restlessness. The results of this study are discussed in context of the literature on clinical phenomenology of akathisia. We propose a symptom-severity model of akathisia emphasizing psychodynamic aspects with considerable consequences for diagnosis and quantification of the disorder. The model points to the relevance of patient exploration for optimizing diagnostic reliability and should be taken into account when developing new and valid akathisia rating instruments.

Adolescent↗
PubMed1991

[NMR tomographic diagnosis with Gd-DTPA in HIV-associated diseases in the head-neck area].

In a prospective study 21 patients suffering from HIV-1 infection underwent MR imaging. The following tumours were found: eight Kaposi's sarcomas, four lymphomas, two squamous-cell carcinomas, and three cases of lymphoid hyperplasia. Furthermore, three cases with lymphoepithelial cysts and one case of inflammatory changes of the parotid glands were studied. Optimal diagnostic results were obtained by using T1- and T2-weighted sequences plain and Gd-DTPA enhanced. Different signal intensities enabled the differentiation of lesions such as inflammation, lymphomas and lymphoid hyperplasia. Besides clinical examination modalities, MR imaging proves to be an important tool in investigating solid, cystic or inflamed processes in HIV-positive patients in the head and neck area.

Carcinoma, Squamous Cell↗
PubMed1987

[Obstetric management in severe fetal growth retardation. Report of experiences based on 278 newborn infants with severe dystrophy 1970-1985].

The article discusses and reviews the obstetrical modalities in confirmed severe growth retardation and the effects exercised by marked dystrophy of newborn (less than or equal to 3rd percentile of weight) at the Department of Gynaecology of the University of Cologne between 1970 and 1985 on perinatal mortality, rate of asphyxiation and neonatal complications. In view of the optimal diagnostic possibilities available during the past decade, the examinations were subdivided into two groups (1970-1975 and 1976-1985). In severe foetal growth retardation-mainly confirmed sonographically-the proportion of primary Caesarean sections increased from 10% to 38%, whereas indication for inducing labour clearly dropped from 25% to 6%. The desired slight reduction in incidence of prenatally severely dystrophic newborn from 1.6% to 1.2% is regarded as the beginning of the effect of ultrasound screening during pregnancy. The higher perinatal mortality of the severely dystrophic newborn of the years 1976-1985 is explained by the increased incidence of dystrophic newborn who are considerably underweight (less than 1000 g) from 1.3% (1970-1985) to 10.4% (1976-1985). If perinatal mortality rate is corrected accordingly, perinatal mortality for both groups is about equal, namely, 3.3% and 3.2% respectively. Among the severely dystrophic newborn there were distinct differences on comparing the two groups in respect of the degree of maturity depending on the pregnancy period, and of the weight at birth. In 1970-75 85% of the dystrophic children were born after the 37th pregnancy week, i.e. mature-dystrophic, and only 15% showed in addition the signs of immaturity.(ABSTRACT TRUNCATED AT 250 WORDS)

Apgar Score↗
PubMed1986

[Magnetic resonance tomography in suspected acoustic neurinoma: technic and differential diagnosis].

Sixty-five patients with suspected acoustic neuromas were examined by CT and MR; the optimal diagnostic procedures are discussed. Extrameatal acoustic neuromas (11 cases) were all diagnosed by CT and MR, but only 82% of intrameatal tumours could be diagnosed by CT combined with air cisternography. Using special surface coils and the paramagnetic contrast medium Gd-DTPA, the accuracy of MR was 100%. All tumours greater than 4 mm were demonstrated. Following clinical and neurological examination, MR is the primary diagnostic method in the investigation of acoustic neuromas.

Diagnosis, Differential↗
PubMed1985

[Arthrography of the ankle joint in injuries of the fibular ligament system in children and adolescents].

Arthrography of the ankle is an optimal diagnostic tool in children and adolescents facilitating differential diagnosis between a simple ankle sprain and rupture of the fibular ligaments. It can moreover help to differentiate between rupture of a single and of two ligaments. 35 young patients with surgically confirmed ligamentous rupture were evaluated according to conventional radiographic criteria, and part of them by arthrography. The technique of the latter and the quite frequent normal variants in arthrograms of the ankle in childhood are described. The comparison of the pathologic anatomy disclosed by surgery and the arthrogram reveals a very good correlation. Its main value resides in giving fair information in clinically and radiographically controversial cases.

Adolescent↗
PubMed1985

[Uterus duplication abnormalities with unilateral kidney agenesis, a report on 5 cases].

Uterus malformation with renal agenesis at the same time are rare but well-known in literature. The leading symptom is dysmenorrhoea, pain in the lower abdomen increasing with each menstruation and a growing tumour in the small pelvis. We consider sonography of the small pelvis as being the optimal diagnostic examination. Once the diagnosis has been made, a laparotomy is indispensable. Further proceedings depend on the intraoperative result, whether a reconstruction and/or a partial removement of the inner female genital organs is possible or necessary. We could successfully treat 5 cases of genital malformation with ipsilateral renal agenesis.

Adolescent↗
PubMed2002

Contrasting effect of similar effective regurgitant orifice area in mitral and tricuspid regurgitation: a quantitative Doppler echocardiographic study.

We compared the effect of similar effective regurgitant orifice (ERO) areas in tricuspid regurgitation (TR) and mitral regurgitation (MR) on hemodynamics and volume overload, and examined the impact on grading of TR and MR severity. In a prospective study, 95 patients with TR in sinus rhythm were compared with 95 patients with MR in sinus rhythm matched for ERO area, age, and body surface area. We found that similar ERO area was associated with decreased volume overload in TR compared with MR. There were more women with TR than with MR, but comparison stratified by sex confirmed that regurgitant volume (RVol) was smaller in TR than in MR for similar ERO area. However, patients with systolic venous flow reversal (hepatic for TR and pulmonary for MR) had lower RVol but similar ERO area in TR compared with MR. Therefore, optimal diagnostic thresholds for severe regurgitation (maximum sum of sensitivity and specificity) in TR and MR were different for RVol (45 and 60 mL/beat, respectively) but similar for ERO area (40 mm(2)). We conclude that similar ERO areas induce less RVol in TR than in MR because of the decreased driving force in TR, but have similar consequences with regard to venous flow reversal. Therefore, a similar ERO area grading scheme can be used, and an ERO area of 40 mm(2) or greater is consistent with severe regurgitation in both TR and MR.

Aged↗
PubMed2002

Surgical management of intraductal papillary mucinous tumor of the pancreas.

BACKGROUND: Intraductal papillary mucinous tumor (IPMT) is a type of pancreatic cystic neoplasm. IPMT consists of intraductal papillary mucinous adenoma (benign IPMT) and intraductal papillary mucinous carcinoma (malignant IPMT). Preoperative diagnosis of malignancy is difficult; the invasiveness and metastatic character are not well known. The purpose of the study was to evaluate the optimal diagnostic and therapeutic strategy of IPMT. METHODS: Medical charts of 38 patients with final diagnosis of IPMT in Kyoto University Hospital were retrospectively reviewed. Preoperative imaging, mode of operation, and clinical and histopathologic findings were analyzed. RESULTS: In 38 IPMTs, imaging of localization was correct in 82% by computed tomography, 90% by ultrasonography, 70% by endoscopic retrograde cholangiopancreatography, 100% by magnetic resonance cholangiopancreatography, and 100% by endoscopic ultrasonography. Evaluation of malignancy by endoscopic ultrasonography resulted in sensitivity and specificity of 81% and 78%, respectively. Pylorus-preserving pancreaticoduodenectomy was preferably performed in 20 of 38 patients with IPMT. Twenty-two patients had histologically malignant disease. Half of them had an invasive component in the adjacent stroma. One case of malignant IPMT showed lymph node metastasis, and the patient had no recurrence after pancreaticoduodenectomy with regional lymphadenectomy. No case was diagnosed as margin positive; however, 27% showed a dysplasia with atypia in the epithelial cells of the cut edge of the pancreas. One patient with negative atypia at the cut edge of the pancreas developed a recurrent tumor in the remnant pancreas. CONCLUSIONS: The preoperative diagnosis of malignancy is difficult, and 50% of malignant IPMT showed an invasive component. Thus, radical resection of the pancreas with regional lymph node dissection should be the choice of treatment. Lymph node metastasis and intraductal distant invasion should be carefully managed in the surgical treatment of these lesions.

Adult↗