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[Percutaneous extraction of renal lithiasis without radiological assistance].

OBJECTIVE: To describe the utility of posterior lumbotomy with a 3-4 cm incision through which the finger is inserted to palpate the kidney and perform percutaneous nephrolithotomy when radiological guidance is not available. METHODS: 24 selected patients underwent percutaneous nephrolithotomy. Stone size ranged from 1-4 cm. The calculi were located in the renal pelvis (17 cases), lower calyx (6 cases), inferior pyelocalyceal level (2 cases) inferior and mid-calyceal level (1 case). RESULTS: Calculi less than 1.5 cm were completely removed and ultrasonic lithotripsy and stone extraction with forceps were effective in the remaining cases. Twenty-four kidneys required a single stage procedure. Complications were observed in 12.5% of the cases. CONCLUSIONS: Posterior lumbotomy with a 3-4 cm incision to palpate the kidney and perform percutaneous nephrolithotomy, is useful when radiological guidance is not available.

Adult↗

Intraoperative methods to stage and localize pancreatic and duodenal tumors.

Intraoperative methods to stage and localize tumors have dramatically improved. Advances include less invasive methods to obtain comparable results and precise localization of previously occult tumors. The use of new technology including laparoscopy and ultrasound has provided some of these advances, while improved operative techniques have provided others. Laparoscopy with ultrasound has allowed for improved staging of patients with pancreatic cancer and exclusion of patients who are not resectable for cure. We performed laparoscopy with ultrasound on 50 consecutive patients with adenocarcinoma of the pancreas or liver who appeared to have resectable tumors based on preoperative computed tomography. 22 patients (44%) were found to be unresectable because of tumor nodules on the liver and/or peritoneal surfaces or unsuspected distant nodal or liver metastases. The site of disease making the patient unresectable was confirmed by biopsy in each case. Of the 28 remaining patients in whom laparoscopic ultrasound predicted to be resectable for cure, 26 (93%) had all tumor removed. Thus laparoscopy with ultrasound was the best method to select patients for curative surgery. Intraoperative ultrasound (IOUS) has been a critical method to identify insulinomas that are not palpable. Nonpalpable tumors are most commonly in the pancreatic head. Because the pancreatic head is thick and insulinomas are small, of 9 pancreatic head insulinomas only 3 (33%) were palpable. However, IOUS precisely identified each (100%). Others have recommended blind distal pancreatectomy for individuals with insulinoma in whom no tumor can be identified. However, our data suggest that this procedure is contraindicated as these occult tumors are usually within the pancreatic head. Recent series suggest that previously missed gastrinomas are commonly in the duodenum. IOUS is not able to identify these tumors, but other methods can. Of 27 patients with 31 duodenal gastrinomas, palpation identified 19 (61%). IOUS did not image a single tumor that was not palpable. Endoscopy with duodenal transillumination found an additional 7 tumors (84%), and duodenotomy identified an additional 5 (100%). Thus duodenotomy (opening the duodenum) is indicated in all patients with gastrinoma as duodenal tumors are missed by other means including ultrasound, palpation and transillumination. In conclusion, laparoscopy with ultrasound is useful for selecting patients with pancreatic cancer for curative surgery. Ultrasound is critical for operative identification of insulinomas especially in the pancreatic head, and duodenotomy can identify duodenal wall gastrinomas that are missed by other methods.

Adenocarcinoma↗

[Physical medicine in the diagnosis and treatment of functional disorders of the spinal column].

INTRODUCTION: Manual (Physical) Medicine is concerned with physiology, pathophysiology, diagnosis and therapy of the musculoskeletal system functional disorders. Functional disorders are caused by direct or indirect injury (muscular spasm), inflammation, sudden movements etc. Functional disorders in regard to decreased joint volume are also called segmental or peripheral joint dysfunction, somatic dysfunction and function blocking. Blocking means: reversible disorder with decreased functional joint movement; muscular spasms caused by neurophysiological changes including decreased movement; pain and functional disorder of internal organs and tissues being part of the joint. Intervertebral joints, intervertebral discs, muscles and their nerve control belong to such control circles which are integrated within an organism. The basic principles of Manual (Physical) Medicine are good knowledge of functional anatomy and three-dimensional imaging of biochemical functions of the spine. The most important functions of the spinal column are as follows: it is an organ of axis with a protective and supportive function and it enables normal walk and balance. The basic functional unit in the architecture of the vertebral column is the dynamic spinal segment. Its basic function is movement, posture maintenance and protection of spinal nerve roots. The functional disorder of one part of the dynamic segment cannot be isolated from other parts. Thus functional blocks within the fascial joints, abnormalities within intervertebral discs, changes within the ligament apparatus, and muscular disorders may be both causes and consequences at the same time. The dynamic segment is thus included into a mechanical functional circle. Its mechanical function is tightly connected with the statics of the whole body. Different leg length, severe abnormalities of great leg joints may cause blocks within the fascial joints. The vertebral dynamic segment is also a part of the nervous, functional reflex circle. Clinical symptoms associated with functional disorders within intervertebral joints are as follows: restricted joint mobility and nervous reflex disorders (local segmental and peripheral segmental injuries). MANUAL (PHYSICAL) DIAGNOSIS: In order to make physical diagnosis it is necessary to have good knowledge of anatomy, functional anatomy, kinesiology and neurology. History taking is of great importance for the physician who establishes physical therapy. It is also necessary to note various abnormalities, muscle atrophy and to analyze patient's walk. Palpation at rest reveals changes, skin disorders, subcutaneous and fatty tissues and muscles and it assesses the status of soft tissues. By physical examination of the spine it is possible to diagnose intervertebral joint blocks. Thus examination of joint mobility is performed. It is important to differ physiological, anatomic and pathologic ranges of mobility and to determine the greatest mobility and joint play. Joint play represents the property of the joint to achieve some additional mobility. This examination requires knowledge of a special technique. Palpation of local segmental irritation is performed on all spinal segments after a special technique examining bone-transversal joints as well as sacroiliac joints. Local irritation points, muscle spasms and tendomyosis are being detected. The diagnosis of blocks is also the therapeutic diagnosis at the same time. Physicians using physical medicine must apply x-ray of the spinal column, whereas the aim of physical therapy is to eliminate functional blocks, which occur in the form of reduced reversible mobility in one or more directions. Only physical examination can establish this, while apparatuses cannot objectivize it. Manipulative techniques on the spine should be performed only by specialists. MANUAL (PHYSICAL) THERAPY: Manual (Physical) therapy comprises numerous techniques and is used in various indications. (ABSTRACT TRUNCATED)

Contraindications↗

Is routine scrotal ultrasound advantageous in infertile men?

PURPOSE: We determine the value of routine scrotal ultrasonography in the evaluation of male infertility. MATERIALS AND METHODS: Scrotal color Doppler ultrasonography reports of 1,372 infertile men were reviewed to assess the prevalence of scrotal abnormalities and compared to clinical findings. RESULTS: The prevalence of scrotal abnormalities was 38%. Testicular tumor was found in 0.5%, varicocele in 29.7%, testicular cyst in 0.7%, testicular microlithiasis in 0.9%, epididymal cyst in 7.6% and hydrocele in 3.2% of the cases. Overall, 67% of sonography findings were not evident on palpation, and only 1 of 7 testicular tumors was suspected. Of the varicoceles 60% were not found on physical examination. The rate of testicular tumors (1/200) was higher than that reported for the general European population (1/20,000). CONCLUSIONS: Routine scrotal ultrasound provides valuable information in the diagnostic evaluation of infertile men and substantially more pathological conditions are detected compared to clinical palpation. The high prevalence of testicular malignancies underlines the clinical relevance of routine scrotal ultrasonography in infertile men.

Adult↗

Sonographically guided aspiration cytology of neck nodes for selection of treatment and follow-up in patients with N0 head and neck cancer.

BACKGROUND AND PURPOSE: The management of the clinically negative neck (NO) remains controversial because the incidence of occult metastases is high and the prognostic difference between elective treatment and a "wait and see" approach remains unclear. This study was undertaken to assess the role of sonographically guided aspiration cytology for the selection of the initial-management strategy for the neck and for the early detection of neck metastases during follow-up of patients with NO. METHODS: Seventy-seven clinically and cytologically confirmed NO patients, who underwent a transoral tumor excision and no neck treatment, were followed up for 1 to 4 years by both palpation and sonographically guided aspiration cytology. RESULTS: Fourteen patients (18%) had recurrent neck tumor; 10 (71%) of these necks were salvaged. Of the 14 neck failures, six were detected before being palpable and nine were detected within 7 months. Eleven of the 19 aspirated tumor-positive nodes had a minimal diameter smaller than 1 cm, and all four patients who eventually died had lymph node metastases larger than 14 mm. CONCLUSION: With sonographically guided aspiration cytology, the risk of missing occult metastases was 18%, which is less than expected after palpation only. Sonographically guided aspiration cytology is an effective technique for following up on the status of the neck after transoral tumor excision, and should be used at frequent intervals if no elective neck treatment is performed.

Adult↗

Augmentation of the nasal spine area with tissue bone matrix sponge.

OBJECTIVE: High-density tissue bone matrix (TBM) sponge is a homograft derived from human cadaver. It is reported to be osteoinductive. The objective of this paper is to measure the bone formation and cosmetic effect of TBM sponge implanted in the nasal spine area of patients undergoing rhinoplasty with retraction of this region and loss of nasal tip support. DESIGN: The study was designed as a prospective trial. SETTING: Patients were selected from private facial cosmetic practice and from public otolaryngology practice. PATIENTS: Six patients were selected who had retraction of the nasal spine area and loss of tip support. INTERVENTION: Patients had implantation of the TBM sponge in the nasal spine area either as a sole procedure or in conjunction with other rhinoplasty maneuvers. MAIN OUTCOME MEASURES: Palpation was used to assess position, size and consistency of the implant. Cosmetic effect was assessed by computer imaging, which was used to measure nasolabial angle and tip projection. Bone formation was assessed by computed tomography scanning. RESULTS: The implant could be palpated in all six patients at 1 month postoperatively, but at 3 months was either smaller or could not be felt. Nasolabial angle and tip projection were improved in all patients initially, but 3 months following surgery this cosmetic improvement was maintained in only two patients. At 3 months, CT scanning showed no evidence of bone formation. CONCLUSION: The TBM sponge was not found to be osteoinductive or permanent when implanted in the nasal spine area and therefore is not a good implant in that region.

Bone Matrix↗

The effect of an occlusal interference on the masticatory system. An experimental investigation.

An experimental short term study on the effect of an occlusal interference on the path of closure of the mandible was carried out on 8 persons. The interference consisted of a gold inlay placed unilaterally in one of the mandibular first molars. Clinical and electromyographic studies revealed functional disturbances or pain in all subjects. The masticatory musculature was tender to palpation and showed coordinational disturbances; the TMJ showed tenderness to palpation, clicking and irregular movements and the interfering teeth periodontal tenderness.

Adult↗

Intraoperative use of gamma-detecting probes to localize neuroendocrine tumors.

Neuroendocrine tumors are characterized by the expression of different peptides and biogenic amines. These rare tumors tend to grow slowly and are notoriously difficult to localize, at least in the early stages. Surgical removal is the only definitive therapeutic option for neuroendocrine tumors and relief from hyperfunctional status. The effectiveness of surgical treatment is invariably dependent upon the complete surgical excision of all tumor tissue, because microscopic and occult disease not readily seen by the surgeon may remain in situ, leading to shortened survival. Therefore, pre- and intraoperative localization of the primary as well as of metastatic tumors is of utmost importance. Radioguided surgery (RGS) is an intraoperative technique that enables the surgeon to localize radiolabelled tissue based on the characteristics of the various tissues. Concerning gastroenteropancreatic tumors (GEP), intraoperative gamma probe examination is able to reveal small tumor sites accumulating (111In-DTPA-D-Phe1)-pentetreotide more efficiently (> 90%) than somatostatin receptor scintigraphy (68%-77%), because lesions with a size smaller than 5 mm in greatest dimension could be identified. Furthermore, RGS identified 57% more lesions when compared to the "palpating finger" of the surgeon. In medullary thyroid cancer (MTC), surgical removal of the tumor is the first and most efficient treatment of the disease. Persistent or increasing serum calcitonin and carcinoembryonic antigen (CEA) levels imply tumor recurrence after thyroid ablation. For imaging recurrent MTC many radiopharmaceuticals have been used to visualize tumor sites, but none of them has shown excellent sensitivity. Preoperative somatostatin receptor scintigraphy and intraoperative RGS in patients with recurrent MTC demonstrate only part of the tumor sites and cannot visualize small tumor sites (less than 10 mm). In comparison, RGS using 99mTc(V)-DMSA detects metastases with a size of 5 mm in diameter, whereas the "palpating finger" of the surgeon localized metastases with a size of more than 1 cm in diameter. In patients with recurrent MTC, intraoperative gamma probe examination is able to localize over 30% more tumor lesions when compared with conventional preoperative imaging modalities and surgical findings. MIBG scintigraphy is the most sensitive technique for the detection and staging of neuroblastoma (sensitivity 92%; specificity nearly 100%). Intraoperative RGS with iodine labelled MIBG has been developed to improve the definition of tumor limits or to localize small, nonpalpable tumors. Comparison of 123I- and 125I-labelled MIBG revealed a sensitivity of 91% and 92%, respectively; the specificity of 125I (85%) was significantly higher than that of 123I (55%). In addition to scintigraphy of the adrenal glands by precusors of adrenal hormones, imaging with a radiolabelled somatostatin analogue is possible; however, (111In-DTPA-D-Phe1)-pentetreotide is not specific for any adrenal disease or function and the relatively high radioligand accumulation in the kidneys limited the use for detection of tumors in the area of the adrenal glands.

Endocrine Gland Neoplasms↗

[Therapy of the Melkersson-Rosenthal syndrome with kenalog].

IA case of Melkersson-Rosenthal syndrome with major and minor symptoms is presented. Clinical diagnosis was established on the basis of the triad: macrocheilia, lingua plicata and facial paralysis and a number of minor symptoms. The upper lip macrocheilia with palpation evident infiltrates corresponded to the diagnosis of granulomatous cheilitis of the upper lip. The upper lip was of intense red color, with the vermilion border effaced causing a marked cosmetic defect. The predominant subjective symptoms were burning and itching sensations with a reduction of movement of the lip. Clinical examination and palpation revealed three granulations enclosed by fissures. A slight exfoliation of the epithelia with serous exudate was dominant feature. The patient was admitted to the Oral Medicine Department of Dental School in Sarajevo on October 8th 1999 for macrocheilia relapses. The therapy using subcutaneous application of kenalog-40 suspension once a week in duration of five weeks showed substantial improvement. According to the prognostic criteria and the control examinations there were no relapses.

Adult↗

Atrial fibrillation: a comparison of methods to identify cases in general practice.

The importance of atrial fibrillation as a treatable risk factor for stroke is well established. Less is known about how to find previously unidentified cases within the community so that antithrombotic treatment can be offered to a wider group of at-risk patients. The aim of our study was to examine ways to improve the efficiency of practice-based screening for atrial fibrillation, including issues of time and financial cost. We used different combinations of pulse palpation and interpretation of 12-lead and bipolar electrocardiographs as carried out by practice nurses. The best strategy for the detection of atrial fibrillation in a practice population would appear to be to screen all eligible subjects by nurse pulse palpation, followed by 12-lead electrocardiograph readings in those who have a pulse suggestive of atrial fibrillation. The electrocardiograph interpretation can be undertaken effectively by a trained nurse.

Aged↗

Observer variation in the diagnosis of thyroid disorders. Criteria for and impact on diagnostic decision-making.

The thesis is concerned with the reliability of thyroid diagnostic modalities. When no "true" diagnosis was available the reliability could not be evaluated by assessing the accuracy; in these cases the reproducibility was evaluated. This was done by evaluating the observer variation: comparison of observers' evaluation in pairs was assessed. The observer variation was expressed by the kappa coefficient, which adjusts to the amount of agreement that can be expected to occur by chance alone. Clinical estimation only of thyroid functional status was subject to considerable observer variation. Likewise clinical estimation the thyroid gland (size and morphology) was subject to considerable observer variation, and the observer variation was greatest concerning the palpation of a solitary thyroid nodule where even experienced doctors had difficulties in reproducing their own evaluations. In contrast high reproducibility was found concerning the interpretation of routine thyroid blood tests. Thyroid scintigram is not suitable for thyroid size estimation. Assessment of thyroid morphology (diffuse, multinodular, solitary hot or cold lesion) based on scintigram alone seldom resulted in acceptable reproducibility: four doctors diagnosed a solitary cold lesion in 100 of 480 scintigrams, however, they only agreed in 30 of the cases. A solitary cold lesion may in a few per cent of the cases imply malignancy and will therefore lead to further investigations. The reproducibility was not improved when the doctors had additional access to patient history and clinical examination as well as the scintigram. Ultrasound is increasingly often regarded as the "true" diagnosis in the morphological description of the thyroid gland. In a study of two specialists in thyroid ultrasound these descriptions were, however, found not to be reproducible. Thus ultrasound should be applied with caution as the golden standard with regard to thyroid type. It has been demonstrated that thyroid imaging is subject to considerable observer variation. This has great implications when thyroid imaging is used as the golden standard, for example when patients are selected for scientific studies. Furthermore, this may influence the comparison of different studies because of inconsistency of the material included. Therefore the observer variation should appear from description of material and methods in scientific studies. Palpation of thyroid size is neither accurate nor reproducible if an exact volume is aimed at. A rough division into small, medium, and large goitres is reproducible and rather accurate and may therefore be applied. In a prospective randomised study it was demonstrated that this division could replace ultrasound estimation of thyroid size in the calculation of 131I dose in the treatment of hyperthyroidism. Evaluation of thyroid functional status cannot be based on patient history and clinical examination alone, it should include thyroid blood tests. Exact estimation of thyroid size should be performed by means of ultrasound. When morphology of the thyroid is assessed the observer variation should be kept in mind. The existence of observer variation implies uncertainty concerning patient material and inclusion criteria in scientific studies. It may complicate comparison of scientific results. In thyroid diagnostic decision-making doctors should keep in mind that even though there is agreement concerning thyroid blood tests there is not agreement concerning thyroid imaging and the clinical evaluation of patients suspected of thyroid disorders. The patients may experience these disagreements even if the same doctor follows them. Doctors are obliged to use the existing modalities and should be aware of not only problems with technology but also variations originating from the observers, the doctors themselves--the human factor.

Humans↗

[A case of breast cancer 5 cm in diameter treated with a breast preserving approach after preoperative intra-arterial chemotherapy].

The patient was a 59-year-old female with a mass in the right breast (area C). At the initial examination, the mass was 5.0 x 4.5 cm on palpation, aspiration cytology was Class V, and a diagnosis of T2aN1aM0, Stage II breast cancer was made. Since the patient strongly desired a breast preserving treatment, a reduction in the size of the mass was attempted by local intra-arterial chemotherapy. Docetaxel (TXT) was administered at 60 mg into the internal thoracic artery and lateral thoracic artery at a rate of once a month for a total of 5 times. After the fifth treatment, the mass was reduced in size to 2.8 x 2.5 cm on palpation, and breast-preserving resection was then carried out. On histopathological examination, cancer was observed in an area of 3.0 x 2.2 cm. Careful follow-up is still needed, but preoperative intra-arterial chemotherapy is considered to be significant as a step before breast preserving surgery for breast cancer with a diameter of 3-5 cm.

Antineoplastic Agents, Phytogenic↗

[Usefulness of CT colonography in the preoperative evaluation of patients with distal occlusive colorectal carcinoma].

PURPOSE: To evaluate the role of preoperative virtual colonoscopy to study the proximal colon in patients with distal occlusive carcinomas, diagnosed by conventional colonoscopy. MATERIAL AND METHODS: We examined 19 patients aged 46 to 83 years (13 men and 6 women) with distal occlusive colorectal carcinomas diagnosed by conventional colonoscopy, who were preoperatively studied with virtual colonoscopy. Patients with acute bowel obstruction were excluded. Results were compared with the findings of preoperative conventional colonoscopy and barium enema examination, intraoperative colon palpation, histopathologic outcome, postoperative conventional colonoscopy and barium enema examination. RESULTS: Virtual colonoscopy identified all 19 distal occlusive colon carcinomas and 22 synchronous lesions, 2 cancers (prevalence 10,6%) and 20 polyps (prevalence 68,4%). Both synchronous cancers were confirmed intraoperatively by direct palpation. Postoperative conventional colonoscopy, which was performed in 18 patients, confirmed the presence of 15 polyps in 12 patients. Three subcentimeter polyps were removed during conventional colonoscopy and were missed at virtual colonoscopy. Two polyps shown by virtual colonoscopy were not found at conventional colonoscopy. Postoperative barium enema was performed in three patients and confirmed three polyps identified at virtual colonoscopy. Preoperative barium enema was performed in five patients and failed to adequately demonstrate the proximal colon. Virtual colonoscopy showed a sensitivity of 87% and a specificity of 75%. CONCLUSIONS: Virtual CT colonoscopy can be considered an important diagnostic technique to evaluate preoperatively the proximal colon in patients with distal occlusive carcinomas,as it gives better results than barium enema or conventional colonoscopy, as well as being well tolerated and less invasive.

Adenocarcinoma↗

Insulinoma: diagnostic strategies and surgical treatment. A 22-year experience.

BACKGROUND/AIMS: The efficacy of preoperative localization methods and the results of the surgical treatment of insulinoma were studied. METHODOLOGY: Fifty-nine patients referred for surgical treatment were studied and the results of the diagnostic tools for tumor localization were compared with findings at surgical intervention. The influence of the type of surgical procedure in the immediate and late postoperative course was also studied. RESULTS: Ultrasonography had a sensitivity of 30%, computed tomography 25%, angiography 54%, portal vein sampling 94%, endoscopic ultrasonography 27% and magnetic resonance 17%. Intraoperative palpation localized 98.2% of the tumors and by the addition of intraoperative echography, all lesions were identified. In 55 patients with benign lesions, 22 enucleations, 25 distal pancreatectomies, 7 pancreatectomies plus enucleation and one duodenopancreatectomy were performed. Malignant tumors were treated by pancreatic resection, postoperative hepatic artery embolization and systemic chemotherapy. There was no postoperative mortality. Pancreatic fistula was the most common complication. Three patients who underwent distal pancreatectomy developed late diabetes (9.3%). CONCLUSIONS: Extensive preoperative investigation, mainly with invasive methods, is not indicated and by combining intraoperative palpation and echography most of the cases can be adequately dealt with. Preservation of pancreatic tissue with enucleation and preservation of the spleen are the best choice for treatment of benign insulinomas.

Adolescent↗

Scurvy: a case report.

An 8-year-old child with cerebral palsy came with progressive purpuric rash affecting the trunk and legs. He had tenderness on palpation of his extremities. Physical examination revealed a moderately pale and cachectic boy. There was bleeding per swollen gums and petichiae on the hard palate. Generalized multiple discrete palpable petichiae spots at hair follicles along the whole body, more on both legs, were observed. He also had tenderness on palpation of his extremities. His hemoglobin was 6.6 g/dl. Platelet count and coagulogram were normal. Roentgenographic findings showed generalized osteoporosis, metaphyseal white line of distal femur, proximal tibia. proximal fibula, distal radius, and distal ulna with submetaphyseal lucency bilaterally. Skin biopsy showed dilated hair follicles, filled with keratinous material and a small corkscrew hair. A diagnosis of scurvy was made; and vitamin C at a dosage of 300 mg per day was given. His swollen gums, bleeding per gums and muscle tenderness improved within 2 days. Perifollicular hemorrhage, follicular hyperkeratosis, and anemia improved in 2 and 3 weeks respectively.

Ascorbic Acid↗

Back, chest and abdominal pain. How good are spinal signs at identifying musculoskeletal causes of back, chest or abdominal pain?

BACKGROUND: Spinal signs found in association with atypical chest and abdominal pain may suggest the pain is referred from the thoracic spine. However, the prevalence of such signs in these conditions has rarely been compared with that in those without pain. In this study, the prevalence of spinal signs and dysfunction in patients with back, chest and abdominal pain is compared with that in pain free controls. The aim of the study is to determine the significance of spinal findings in patients with such pain. METHODS: A general practitioner blinded to the patients' histories performed a cervical and thoracic spinal examination on general practice patients with back, chest and/or abdominal pain and on controls without pain. Thoracic intervertebral dysfunction was diagnosed on the basis of movement and palpation findings. RESULTS: Seventy-three study patients plus 24 controls, were examined. For cervical spinal signs, pain in the back, chest and/or abdomen was associated with pain with active movements and overpressure at end range and with loss of movement range. For thoracic spinal signs, this association held for pain with active movements and overpressure, but not with loss of movement range. The prevalence of thoracic intervertebral dysfunction was 25.0% in controls, 65.5% with chest/abdominal pain, 72.0% with back pain and 79.0% with back pain with chest/abdominal pain. This prevalence was higher with chest pain than with abdominal pain. CONCLUSIONS: The results show an association, but not a causal link between thoracic intervertebral dysfunction and atypical chest/abdominal pain. A spinal examination should be performed routinely assessing these conditions. The minimum examination for the detection of intervertebral dysfunction is testing for pain with spinal movements and palpation for tenderness. The interpretation of positive signs requires knowledge of their prevalence in pain free controls and in patients with visceral disease.

Abdominal Pain↗

The effects of creatine supplementation on exercise-induced muscle damage.

This investigation evaluated the effects of oral creatine (Cr) supplementation on markers of exercise-induced muscle damage following high-force eccentric exercise in subjects randomly administered Cr or placebo (P) in a double-blind fashion. When injected, exogenous phosphocreatine has been shown to stabilize the muscle membrane in cardiac tissue and enhance recovery of strength and power following injury. Twenty-three men aged 18-36 years ingested either 20 g of Cr or P for 5 days. Criterion measures were maximal isometric force of the elbow flexors (MIF), range of motion (ROM) about the elbow, mid and distal arm circumference (CIR; to assess swelling), soreness with movement and palpation (SOR), and blood levels of creatine kinase (CK) and lactate dehydrogenase (LDH). Following the supplementation period, subjects performed 50 maximal eccentric contractions of the elbow flexors. Criterion measures were assessed pre-exercise, immediately postexercise, and for 5 days after exercise. Both groups experienced a significant loss of MIF and ROM (time effect, p < 0.05). There was a significant increase in CIR of the mid and distal biceps, SOR with movement and palpation, CK, and LDH (time effect, p < 0.05), indicating that there was significant muscle damage. However, there were no significant differences in any of the criterion measures between groups (group x time interaction term, p > 0.05). The pattern of change over the 6 days, in response to the eccentric exercise, was nearly identical between groups. These data suggest that 5 days of Cr supplementation does not reduce indirect markers of muscle damage or enhance recovery from high-force eccentric exercise.

Adult↗

Paroxysmal hypertension, pheochromocytoma, and pregnancy.

BACKGROUND: Hypertension is the most common medical complication of pregnancy. Pheochromocytoma in pregnancy is rare, and if unrecognized, can cause serious perinatal morbidity and mortality. METHODS: A patient with severe hypertension, postpartum pulmonary edema, and a recognized pheochromocytoma is described. RESULTS: Abdominal palpation after vaginal childbirth reproduced the diagnostic triad of hypertension, headaches, and palpitations. Magnetic resonance imaging established the correct diagnosis before biochemical confirmation of excess catecholamine production. The patient responded to alpha-adrenergic receptor blockade with control of her severe hypertension and clearing of pulmonary edema. The best time to diagnose a pheochromocytoma is before delivery because vaginal childbirth stimulates the release of lethal amounts of catecholamines. CONCLUSIONS: The physician who delivers babies must distinguish between labile hypertension and paroxysmal hypertension. Most experts believe that a spontaneous vaginal delivery is contraindicated when the patient has a pheochromocytoma. Postpartum pulmonary edema associated with a pheochromocytoma is unusual. The profound pressor response elicited by palpation of the postpartum abdomen, the failure of medications usually effective in the treatment of a hypertensive crisis, and the use of magnetic resonance imaging to confirm a functioning adrenal adenoma are the features unique to this case.

Adrenal Gland Neoplasms↗