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PubMed1991

The role of bone scintigraphy in the evaluation of talar dome fractures.

We undertook a retrospective study of 122 patients with ankle pain to determine the accuracy of bone scintigraphy using 99mTc-methylene diphosphonate (MDP) for detection of osteochondral talar dome fractures (OCTDF). Plain radiographs, which were available in 97 patients, had not revealed any abnormality in the talar dome. Bone scintigraphy was followed by CT, which was considered to be the reference test in diagnosing OCTDF. Analysis of our data showed that when the bone scan findings in the two highest confidence categories (high and moderate probability) were accepted as abnormal, the sensitivity and the specificity of the test were 0.94 and 0.76, respectively. Although CT is mandatory to establish the stage of OCTDF, it cannot be used routinely due to its high cost. Bone scintigraphy appears to be a good screening procedure that will identify patients who are likely to benefit from further radiographic studies such as CT. These findings are subject to further confirmation in a prospective study.

Adolescent↗
PubMed1985

Evaluating the undescended testis.

This problem is often associated with other anomalies which, if present, are usually evident on the initial examination. Therapy before age two is mandatory to preserve fertility. The malignant potential of undescended testes is well established. Placement of the testes into the scrotum facilitates frequent examinations. All postpubertal patients with intra-abdominal testes, as well as patients who have inguinal testes and are between puberty and age 50, should be referred for orchiectomy.

Adolescent↗
PubMed1978

Functional and dysfunctional uterine bleeding.

The patient who comes to the physician with abnormal bleeding represents an enormous responsibility. The various causative factors represent defects in numerous physiologic systems. The diagnosis of DUB still requires further investigation of the hormonal imbalance. Only when specific causes are known can the treatment be tailored to the particular patient. Recent scientific advances regarding possible cellular mechanisms for DUB make it mandatory that the primary physician be aware of available tests that may indicate the relative appropriateness of and prognosis for a particular therapy. The treatment is substitutional. If progesterone is missing, therefore,the treatment should replace it. Progesterone may be obtained endogenously by ovulation induction or exogenously by oral or parenteral progestogens.

Adolescent↗
PubMed1980

[Improvement in brain circulation by microsurgical bypass anastomoses].

On the basis of 100 patients operated during the last ten years at the Neurosurgical University Clinic of Zurich the experiences with the extra-intracranial bypass anastomosis for stroke patients are examined. The risks of this surgery are low (morbidity 2%, mortality 3%) and the patency rate is high (94.3%). The main purpose of this intervention is to prevent or minimize further strokes. This risk was decreased from 40% of non operated cases in the literature to 4.2% in this series. Severe neurological deficits are not improved by surgery. The procedure is therefore indicated for mild forms of cerebral ischemia (TIA's and mild strokes), when the disease is caused by an appropriate obstruction of the internal carotid artery and/or middle cerebral artery which are inaccessible to surgery of the neck. For this latter reason preoperative carotid angiography is mandatory. To avoid unnecessary angiography, the carotid Doppler ultrasound test and dynamic brain scanning are valuable, non invasive screening methods for indicating angiography in eah individual case.

Adolescent↗
PubMed1994

Evaluation and treatment of poisonous snakebites.

Snakebite victims should be transported immediately to the nearest emergency department. Incision and suction are contraindicated unless performed by experienced personnel within five minutes of the bite, or unless transport of the patient to definitive medical care will take more than 30 minutes. Cryotherapy is contraindicated. All bites should be graded for severity of envenomation. The wound should be cleaned and broad-spectrum antibiotics administered. Tetanus status should be determined and tetanus toxoid administered if necessary. Antivenin is indicated in certain mild cases and in all moderate and severe cases of envenomation. Patients with a mild case of envenomation may require up to five vials of antivenin; patients with moderate bites may require 10 to 15 vials, and patients with severe bites may require 15 to 20 vials. Antivenin is effective only when administered intravenously; skin testing to predict the possibility of anaphylactic reaction is mandatory before administration. Diphenhydramine and epinephrine should be readily available in case of anaphylaxis. Fasciotomy is only indicated in rare cases involving elevated intracompartment pressures.

Antivenins↗
PubMed1982

Ultrasound evaluation of ectopic pregnancy.

The combined use of a serum radioimmunoassay pregnancy test and high resolution utrasonography allows a more direct approach to be made in the diagnosis of ectopic pregnancy. It is important for ultrasonographers to understand the limitations of the more readily available immunologic pregnancy tests in order to avoid misinterpreting ultrasonograms in the event that a pregnancy test is either falsely positive or falsely negative. Clinical suspicion is mandatory if the early diagnosis of ectopic pregnancy is to be made. The referring physician should take advantage of the highly accurate information resulting from the combined findings of a positive serum HCG and the ultrasonographic images. If the statistics regarding diagnostic delay and tubal rupture are to be improved, these tests should be obtained when a patient is initially evaluated. It is important to recognize that the ultrasonographic interpretation rests primarily upon the uterine findings. A normal viable intrauterine pregnancy essentially excludes the diagnosis of ectopic pregnancy. Other uterine appearances may result from an early intrauterine pregnancy, an abnormal intrauterine gestational event, or, as in approximately 1 per cent of pregnancies, an ectopic gestation. Subsequent evaluation in suspicious cases may require a variety of tests including serial HCG determinations, repeat ultrasound examination, uterine dilatation and curettage, culdocentesis, or laparoscopy. It is impossible to recommend a specific schematic approach for any given patient. In part, the pattern of management depends upon availability of tests, the presence or absence of adnexal or cul-de-sac findings, and, of course, the clinical status of the patient.U

Biopsy, Needle↗
PubMed2003

Importance of obtaining independent measures of insulin secretion and insulin sensitivity during the same test: results with the Botnia clamp.

OBJECTIVE: To validate and apply a method for independent assessment of insulin secretion and insulin sensitivity (S(I)) during the same test; that is, an intravenous glucose tolerance test followed by a euglycemic-hyperinsulinemic clamp, also called the Botnia clamp. This test was then applied to nondiabetic subjects with (FH+) and without (FH-) a first-degree family history of diabetes. RESEARCH DESIGN AND METHODS: The Botnia clamp measures the first-phase insulin response (FPIR) to 0.3g/kg glucose i.v. and insulin sensitivity (M-value) from a 2-h euglycemic clamp begun 60 min after the glucose bolus. The M-value obtained during the Botnia clamp was compared with M-values obtained during a regular euglycemic clamp without prior glucose bolus. Repeated tests were performed in random order in subjects with normal and abnormal glucose tolerance. Finally, the test was applied to subjects with and without a family history of type 2 diabetes. RESULTS: S(I) and insulin secretion from this test showed a high degree of reproducibility, and the M-value obtained with the Botnia clamp correlated strongly with the M-value from a euglycemic clamp without prior glucose bolus (r = 0.953, P < 0.005). FH+ subjects showed decreased S(I) (P = 0.02), but similar FPIR, compared with FH- subjects. However, insulin secretion adjusted for the degree of insulin resistance was significantly impaired (P = 0.04). CONCLUSIONS: In conclusion, the Botnia clamp provides reliable and independent measures of S(I) and beta-cell function during the same test. As illustrated above, knowledge of the degree of S(I) is mandatory when presenting data on insulin secretion.

Diabetes Mellitus↗
PubMed2003

[The aldosterone to Renin ratio in secondary hypertension].

CLASSICAL FEATURES AND SCREENING: The classical features of primary aldosteronism-hypertension, hypokalemia and metabolic alkalosis-were first described by J. Conn in the midfifties of the last century. The classical form of primary aldosteronism is a rare disease with prevalence rates of 0.1-0.5% within the hypertensive population. The normokalemic variant of primary aldosteronism seems to be much more frequent (5-13%). Although a validated and standardized diagnostic protocol for this entity is still missing recent studies established the aldosterone to renin ratio as a useful screening test. To increase diagnostic sensitivity and specificity of the ratio aldosterone should be added as second screening criterion (sensitivity and specificity about 90%). Dynamic confirmatory testing proving autonomous aldosterone secretion is required to verify the diagnosis in case of a positive screening test. A simple confirmatory test is the salt loading test. Alternatively, the fludrocortisone-suppression-test, the Captopril-challenge- test or the daily exretion rate of aldosterone-18-glucuronide and tetrahydroaldosterone in urine can be used. In case of proven primary aldosteronism further diagnostic evaluation (e. g. CT scanning, postural-test and in case of discrepancy adrenal vein catheterization) is mandatory to differentiate the most common forms of primary aldosteronism, aldosterone producing adenoma and idiopathic hyperaldosteronism. Since many patients with primary aldosteronism can be cured by surgery and missing the diagnosis often leads to significant end-organ damage it is important to evaluate hypertensive patients with therapy-resistant hypertension for primary aldosteronism.

Adrenalectomy↗
PubMed1989

Why mandatory HIV antibody screening cannot work.

In 1985 this country introduced the first serologic screening test [enzyme immunoassays (EIAs)] designed to detect antibodies to the human immunodeficiency virus (HIV), the pathogen of acquired immunodeficiency syndrome (AIDS). Some people now suggest use of this test to identify people within the general population who are infected with the virus. This article will review technical and administrative problems pertaining to the use of EIAs to screen the general population for antibodies to HIV, and will explain why optometrists can provide safe and comprehensive care to all patients without knowledge of a patient's HIV antibody status. Prior knowledge by the optometrist of the patient's serological status is unnecessary if the practitioner 1) adheres to established guidelines pertaining to infection control, and 2) is aware of the various ocular manifestations of HIV disease. It concludes that mandatory HIV screening programs should not be adopted until the benefits to society have been more clearly elucidated and associated technical, administrative, and ethical problems have been resolved.

AIDS Serodiagnosis↗
PubMed1990

[Acute tonsillitis: clinical symptoms; bacteriologic culture and rapid test as deciding criteria for the use of antibiotics].

In order to prevent late sequelae from an untreated streptococcal pharyngitis all patients with streptococcal tonsillitis/pharyngitis have to be treated with antibiotics, preferably penicillin. A correct diagnosis by clinical criteria is only achievable in 72% of patients with streptococcal pharyngitis. Additional criteria such as diagnosis by culture are, therefore, mandatory. Time is a major disadvantage of traditional culture methods. Slide agglutination tests show an acceptable sensitivity of 92% and a specificity of 93%. Due to the possibility of false negative test results, with consequent withholding of adequate antimicrobial chemotherapy, these test results should be used only as a valuable guide. Decision to administer an antibiotic should still be based on clinical criteria.

Adolescent↗
PubMed1987

Compulsory premarital screening for the human immunodeficiency virus. Technical and public health considerations.

The effectiveness of a mandatory premarital screening program was examined as a means of curtailing the spread of the human immunodeficiency virus (HIV) infection in the United States. The epidemiology of the HIV, the technical characteristics of tests for antibodies to HIV, and the logistic, economic, and legal implications of such a program were considered. In one year, universal premarital screening in the United States currently would detect fewer than one tenth of 1% of HIV-infected individuals at a cost of substantially more than +100 million. More than 100 infected individuals would be told that they were probably not infected, and there would likely be more than 350 false-positive results. Public education, counseling of individuals, and discretionary testing can be important tools in reducing the spread of HIV infection, but mandatory premarital screening in a population with a low prevalence of infection is a relatively ineffective and inefficient use of resources.

Acquired Immunodeficiency Syndrome↗
PubMed1995

Daily antenatal testing in women with severe preeclampsia.

OBJECTIVE: Our purpose was to determine whether daily antenatal testing in the expectant management of severe preeclampsia remote from term prevents stillbirth or neonatal compromise at birth. STUDY DESIGN: We reviewed the medical records of 68 women with severe preeclampsia remote from term who underwent expectant management with daily fetal testing until delivery. On admission each patient had reassuring nonstress testing (absence of persistent severe variable or late decelerations), biophysical profile (> or = 6), and amniotic fluid volume (> or = 2 cm maximal vertical pocket before 32 weeks or amniotic fluid index > or = 5 after 32 weeks). RESULTS: There were no stillbirths. Twenty-one patients (31%) had nonreassuring testing necessitating delivery. Two neonatal deaths occurred as a result of complications of prematurity. There were no statistical differences in the cord arterial pH (p = 0.93) or in the 1- and 5-minute Apgar scores (p = 0.18 and p = 0.88, respectively) between those with normal and abnormal antenatal testing. CONCLUSIONS: Because optimizing neonatal outcome is the only reason to prolong pregnancy in women with severe preeclampsia, confirmation of fetal well-being is mandatory. Because neither stillbirths nor fetal compromise at birth occurred in patients undergoing daily antenatal testing, we recommend daily testing in patients with severe preeclampsia managed expectantly.

Adolescent↗
PubMed1983

Testing of chemicals by evaluation of their distribution and degradation patterns in an environmental standard system.

Due to the EC directive 79/831 of September 18, 1979, and the German law on hazardous substances, the submission of test data on physical--chemical properties of new substances is mandatory for their registration. These data are supposed to predict in which compartments (air, water, soil, vegetation) the substance will primarily accumulate if it enters the environment. To calculate the distribution of a substance in the environment compartments, different mathematical models have been developed by several working groups, but have not yet been verified in practical experiments. During a prolonged period, the distribution of substances in the environment compartments has been investigated by experiments in an environmental standard system; design and function are explained. Distribution and degradation patterns of 12 reference substances will systematically be investigated, covering a wide spectrum in regard to their physical--chemical properties. Up to now 7 substances have been investigated under standard conditions. The distribution patterns established in these experiments are presented and compared with those obtained mathematically by use of the presently discussed stationary distribution models and values for the physical--chemical properties of the tested substances. The time alterations observed in the distribution patterns are interpreted by a kinetic model which will be part of the calculation method which is presently being developed on the basis of the obtained test values. The good consistency of distribution patterns established by experiments with those established mathematically justifies the assumption that a reliable calculation method of distribution patterns can be submitted as soon as our current work will be finished.

Air Pollutants, Radioactive↗
PubMed2006

[What are the main errors made by surgeons in the management of pancreatic cancer?].

The present review identifies two major conceptual errors. Therapeutic nihilism, which should be discounted in view of the results currently achieved by surgery, and noncentralization, since better results have been demonstrated, both in terms of morbidity and mortality and in survival, in high-volume centers than in low volume centers. The present review also identifies errors in management, the most important of which are: undervaluing the medical record, which is of great utility and continues to be the pillar on which the entire diagnostic process is based; the systematic use of preoperative biliary drainage, which used to be considered mandatory but should be used highly selectively in patients with severe jaundice or biliary tract infections, and viewing preoperative imaging tests as unreliable, when current radiological techniques, particularly helical computed tomography (CT), are highly reliable in establishing tumor resectability and consequently they should be used in all treatment planning. Moreover, because radiological tests are highly reliable, laparoscopic staging has lost diagnostic value; obtaining a preoperative histological diagnosis, which is not mandatory except when neoadjuvant therapy is planned or when tumors requiring nonsurgical treatment are suspected; undervaluing the use of surgical palliation, since this technique provides better long-term results than nonsurgical palliation, and consequently still plays a role in patients with good general health status and prolonged life expectancy; systematically performing gastrojejunostomy with bilio-enteric bypass, as this procedure should only be performed in tumors of the uncus or when there is imminent biliary or gastroduodenal obstruction; the use of supraradical surgical techniques such as regional, total or extensive pancreatectomy, since these techniques do not prolong survival after resection. Furthermore, the use of vascular resections would only be justified if resection with disease-free margins could be performed; undervaluing close postoperative monitoring within specialized units since this is the key to reducing morbidity and mortality rates in this type of surgery; and lastly when an intraoperative pancreatic incidentaloma is present, performing diagnostic maneuvers such as biopsy or pancreatic mobilization, since these procedures hamper subsequent radiological interpretation and possible surgical intervention.

Humans↗
PubMedDate not supplied

Association experiments with aerobic and anaerobic pathogens: a model of in-vitro susceptibility testing in mixed infections. Activity of enoxacin, clindamycin, and metronidazole.

In infections of polymicrobial etiology, it seems mandatory to combine an antibiotic with marginal activity against anaerobes with an anti-anaerobic drug, e.g. metronidazole or clindamycin. We investigated the effect of associations of anaerobic and facultatively anaerobic pathogens on MBCs of enoxacin, clindamycin, metronidazole, and combinations of enoxacin plus clindamycin or metronidazole. Single testing, and associations of Bacteroides fragilis with Escherichia coli or Enterococcus faecalis revealed MBCs of 64 mg/l for enoxacin. However, investigating metronidazole, MBCs for B. fragilis increased from 0.5-1 mg/l to 2-4 mg/l in association with E. coli. The combination of enoxacin with metronidazole restored MBCs of 0.5 and 1 mg/l for the B. fragilis strains. B. fragilis associated with E. faecalis showed MBCs of 2 to 64 mg/l for metronidazole, an increase of up to 64-fold. The enoxacin MBCs for E. coli in association with B. fragilis were up to eight-fold higher than for E. coli alone (2 mg/l compared to 0.25 mg/l). Association of E. coli with E. faecalis and B. fragilis showed a low to moderate increase for MBCs of E. coli when enoxacin was tested alone or in combination with metronidazole or clindamycin. In contrast, MBCs for E. faecalis did not change significantly with any of the associations or combinations tested. It is evident that in vitro antimicrobial susceptibility of associations of pathogens can be modified by interactions between strains, and/or antimicrobials.

Bacteria, Aerobic↗
PubMed2000

Helicobacter pylori prevalence in Leipzig's 1998 school entries: methodology and first results.

The non-invasive, stable-isotope-aided Helicobacter pylori (H. pylori) tests--breath and equivalent urine tests--were offered on a voluntary basis as part of the mandatory school entry medical examination to the 1998 school entry cohort of the City of Leipzig (480,000 residents). Parents of participating subjects were asked to fill out a detailed epidemiologic questionnaire. The response rate was 94% (n = 2228 of 2369 school starters born in 1991/92). Parent-completed questionnaires were returned by 1890 (80%) children. The overall H. pylori positive prevalence was 7.2%. The prevalence among children with a test and a parent-completed questionnaire was 6.5%. Prevalences among subsequently tested family members of the positive tested children was 65, 60 and 39% for mothers, fathers and siblings respectively. Though studies have shown that the direct transmission of the bacterium (oral-oral and fecal-oral) is a dominant pathway of infection, the questionnaire analyses indicate associations between H. pylori colonisation and living as well as environmental conditions.

Breath Tests↗
PubMed1995

Diagnosis of chest pain. Pluses and minuses of stress tests.

The differential diagnosis of chest pain often can be made by careful history taking. However, an adequate physical examination is also important and is considered mandatory by patients. If a definite diagnosis of nonanginal chest pain is made, no further studies are necessary. Electrocardiographic stress tests give important prognostic information in patients with definite angina and also give diagnostic information in patients with atypical angina. They are poor screening procedures for detecting persons at risk for sudden death. Radionuclide and echocardiographic stress tests are expensive and usually not necessary.

Algorithms↗
PubMed1997

Computer-controlled minute ventilation in preterm infants undergoing mechanical ventilation.

INTRODUCTION: Computer-controlled minute ventilation (CCMV) continuously adjusts the ventilator rate to changes in spontaneous respiratory drive and pulmonary mechanics to maintain a preset total minute ventilation. HYPOTHESIS: We hypothesized that CCMV would maintain ventilation and oxygenation with fewer mechanical breaths than conventional intermittent mandatory ventilation in very low birth weight infants. METHODS: Very low birth weight infants in clinically stable condition who were undergoing mechanical ventilation were enrolled. The number of mechanical breaths, total and mechanical expiratory minute ventilation, mean airway pressure, oxygen hemoglobin saturation by pulse oximetry, and transcutaneous partial carbon dioxide and partial oxygen tensions were obtained during intermittent mandatory ventilation and CCMV (45 to 60 minutes) and compared by paired t test. RESULTS: Fifteen infants were studied. Birth weight (median, range) was 700 gm (550 to 1205 gm), gestational age 26 weeks (23 to 34 weeks), age 21 days (3 to 50 days). When switched from intermittent mandatory ventilation to CCMV, the number of mechanical breaths was reduced (15 +/- 2.8 to 8.6 +/- 2.9 breaths per minute, p < 0.001), leading to lower airway pressure (3.97 +/- 1.00 to 3.45 +/- 1.00 cm H2O, p < 0.001) and lower expiratory minute ventilation generated by the mechanical ventilator (116 +/- 31 to 65 +/- 28 ml/min per kilogram, p < 0.001), while total expiratory minute ventilation remained unchanged. Mean transcutaneous partial carbon dioxide and oxygen tensions, oxygen hemoglobin saturation, and the time spent within different oxygen hemoglobin saturation ranges did not differ between both ventilatory modes. CONCLUSION: CCMV maintained adequate ventilation and oxygenation with lower mechanical ventilatory support than IMV. CCMV may reduce barotrauma and chronic lung disease during long-term use.

Down-Regulation↗