Onset Of Complaints Research Articles

An infant with orange-colored urine

Sirs,Changes of the color of urine frequently occur. Mostcommon is the white purulent appearance in urinary tractinfections but also a red color due to hematuria or—mainlyin infants—uric acid. Mere orange discoloration is, how-ever, very rare.An 11-month-old male infant presented with orange-stained diapers. He was otherwise in good health, and theparents reported no additional complaints. History revealedthat the symptoms started several months before presenta-tion. At first onset of complaints, the staining occurred onceor twice a week. During the 3 weeks prior to presentation atour clinic, the frequency increased to a daily basis;generally occurring in the morning. Physical examinationwas unremarkable. Urine showed no erythrocytes, leuko-cytes, or protein in the routine examination. Uric acid was1.2 mmol/l and therefore within the normal range for thepatient’s age. Urine culture revealed a significant amount[>10

Is Gardner-Diamond syndrome associated with hormonal influences along with psychosocial problems? A delayed diagnosis

Auteur(s) : Selda Pelin kartal Durmazlar, Damla Atacan, Bengu Cemil, Fatma Eskioglu Department of Dermatology, Ministry of Health Ankara Diskapi Yildirim Beyazit Education and Research Hospital, Ankara, Turkey Gardner-Diamond syndrome (GDS) is a rare syndrome characterized by spontaneous ecchymoses without definite trauma [1]. Case A 25-year-old woman presented with a 12-year history of spontaneous ecchymoses on her face (figure 1A). Historically, the onset of complaints started [...]

Schwerer fieberhafter Infekt mit Nierenbeteiligung nach Südostasienreise

A 40-year-old teacher fell ill one week after returning from a two weeks back-packing trip to Thailand and Laos. He developed high fever, severe headache, myalgias and a conjunctivitis. CRP and liver enzymes were elevated. The patient developed acute renal failure. Total leucocyte count was normal but the differential count showed an extreme left shift. Imaging procedures revealed hepato-splenomegaly and enlarged kidneys. TREATMENT, COURSE AND DIAGNOSIS: The patient was treated with moxifloxacin and ceftriaxon based on the initial suspicion of a severe infection potentially due to leptospirosis. This treatment led to a rapid improvement of the patient's condition and also of the laboratory findings. Leptospirosis could be confirmed by the seroconversion of specific antibodies to L. grippotyphosa 2 1/2 weeks after onset of complaints (initial serology negative). In febrile travelers returning from Southeast Asia, leptospirosis has to be considered especially in case of severe headache, myalgias, elevated liver enzymes and renal failure and a history of close contact to potentially contaminated water (rivers, lakes). Diagnosis is confirmed by the detection of specific antibodies.

Tuberculosis of the pelvic girdle

Between 1955 and 1980 a total of 67 patients (42 female, 25 male) with advanced tuberculosis of the pelvic girdle underwent surgery at the authors' clinic. In 43 patients the sacroiliac joint was affected (in 2 cases bilaterally), in 11 the ischium, in 9 the pubic bone, and in 2 each the ilium and the sacrum. The average of the patients (who included 4 migrant workers) was 44. The youngest patient was 8, the oldest 67 years old. The average interval between the onset of complaints and diagnosis was 4.6 years (minimum 1 month, maximum 20 years). Thirty-eight of the patients had already had treatment for an organic or osteoarticular tuberculosis. Although 24 (35.8%) of the patients were simultaneously suffering from a florid, specific infection localized elsewhere, and abscesses, fistulas, or a combination of these were identified in 40 patients (59.7%), only 17 (25.4%) were in slightly impaired general condition, and in over one-half of the patients, the hourly blood sedimentation rate was normal or only slightly elevated (up to 20 mm n.W.). In 9 cases (13.4%) the only pointers to tuberculosis were the patient's history, clinical and radiological findings, and the subsequent evolution of the disease. In these cases the diagnosis could not be confirmed either by histologic or by bacteriologic study of focal tissue. In 67 patients, 66 osseous foci were removed and in 2 cases merely an abscess (after an average of 2-3 weeks' tuberculostatic therapy), the bone cavities were filled with a mixture of heterogeneous or autogenous spongiosa and tuberculostatics or merely with chemotherapeutic drugs, and primary closure of the wound was performed.(ABSTRACT TRUNCATED AT 250 WORDS)

Tuberculosis of the shoulder joint

In contrast to specific shoulder girdle processes tuberculoses of the shoulder joint are observed relatively frequently. From 1955 up to and including 1980, 50 patients with omarthritis tuberculosa were surgically treated at the authors' clinic. Thirty were male, 20 female, 42 were Germans, 8 immigrant workers. Arthrodeses were performed in 28 cases, removal of bone or soft-tissue foci, or a combination of these, in 22. The left joint was affected in 26 cases (52%) and the right in 24 (48%). The youngest patient was 9, the oldest 78 years of age (average age 42.6 years). The time from the onset of complaints to diagnosis was about 1.6 years. Twenty-eight patients (56%) had previously had treatment for tuberculosis and 9 (18%) also had active tuberculosis localized elsewhere. Even though there were clear radiological changes in all cases, abscesses and fistulae or a combination of these in 27 cases (54%), the 1-hour ESR was normal or only slightly elevated (under 20 mm acc. to W.) in 29 patients (58%). The recurrences which occurred immediately after surgery or in the subsequent course of the disease healed without sequelae after secondary interventions. While they prolonged hospitalization they did not influence the result of surgery. Of the 38 (76%) patients who were followed up on average 3 years after the end of inpatient treatment, 30 (79%) had returned to work on average 1.1 year after being discharged from the hospital. Three had meanwhile been retrained for lighter work. In the discussion the etiology and pathogenesis, incidence, side localization, age and sex distribution, complaints, clinical and radiological findings, diagnosis, therapy, prognosis, and differential diagnosis of shoulder joint tuberculosis are reported on with reference to the relevant literature.

Heart-type Fatty acid-binding protein in Acute Myocardial infarction Evaluation (FAME): background and design of a diagnostic study in primary care.

BackgroundCurrently used biomarkers for cardiac ischemia are elevated in blood plasma after a delay of several hours and therefore unable to detect acute coronary syndrome (ACS) in a very early stage. General practitioners (GPs), however, are often confronted with patients suspected of ACS within hours after onset of complaints. This ongoing study aims to evaluate the added diagnostic value beyond clinical assessment for a rapid bedside test for heart-type fatty-acid binding protein (H-FABP), a biomarker that is detectable as soon as one hour after onset of ischemia.MethodsParticipating GPs perform a blinded H-FABP rapid bedside test (Cardiodetect®) in patients with symptoms suggestive of ACS such as chest pain or discomfort at rest. All patients, whether referred to hospital or not, undergo electrocardiography (ECG) and venapunction for a plasma troponin test within 12–36 hours after onset of complaints. A final diagnosis will be established by an expert panel consisting of two cardiologists and one general practitioner (blinded to the H-FABP test result), using all available patient information, also including signs and symptoms. The added diagnostic value of the H-FABP test beyond history taking and physical examination will be determined with receiver operating characteristic curves derived from multivariate regression analysis.ConclusionReasons for presenting the design of our study include the prevention of publication bias and unacknowledged alterations in the study aim, design or data-analysis. To our knowledge this study is the first to assess the diagnostic value of H-FABP outside a hospital-setting. Several previous hospital-based studies showed the potential value of H-FABP in diagnosing ACS. Up to now however it is unclear whether these results are equally promising when the test is used in primary care. The first results are expected in the end of 2008.

Das hepatozelluläre Karzinom

Hepatocellular carcinoma (hepatoma) accounts for over 80% of primary liver tumors. Although relatively uncommon in North America and Europe, hepatocellular carcinoma is the dominant malignant carcinoma in Southeast Asia and South and West Africa. About 80% of the patients have cirrhosis. The tumor has a grim prognosis with an average survival time of 4.5-13 months after the onset of complaints. Beginning with the observation of the striking coincidence of the geographic distribution of hepatocellular carcinoma with the endemic distribution of virus hepatitis, many studies have demonstrated the close correlation of the carcinoma with chronic hepatitis B. In the endemic areas vertical perinatal transmission of the virus from mother to the newborn is an important route of transmission. While only about 10% of infected adults develop HBs antigen carrier status, the carrier rate of perinatal infections is about 95%. In chronic infection the virus DNA can be integrated into the host genome and may become carcinogenic with time. Many studies have substantiated an increased incidence of liver adenoma and resulting complications among women taking oral contraceptives; evidence for a relationship between oral contraceptives and hepatoma has not been established. No increase in hepatoma has been observed among young women following the introduction of oral contraceptives in the USA and in Denmark.

The patellar focus, a rare form of localization of bone tuberculosis

Patellar foci of any origin are very rare. Form 1955 to the end of 1979, 9 patients underwent patellar surgery in our hospital. 7 of these patients had tuberculosis, whereas in one case the patient had chronic nonspecific osteomyelitis, and in one case we were unable to clarify the underlying cause of the focus, neither from the histological nor from the bacteriological aspect. All tuberculous foci, one of which had penetrated into the knee joint, were situated in the corpus of the patellar. In a 10-year old girl, the entire patellar was infected with tuberculous foci. In the anterior-posterior x-ray film, the processes mainly presented a circular appearance. Their diameter different between 6 and 25 mm. In one of the foci, two sequesters were conspicuous, and one in another patient. 6 of the patients had an active organ tuberculosis at the same time, or reported on a specific disease during anamnesis. The period from the onset of complaints until diagnosis had been established, was on the average 14.4 months with the 7 patients under investigation (average age 29 years, 4 female/3 male). In view of the fact that all the patients reported here were late cases, the results of the combined drug and surgical removal of foci (filling of the surgical cavities with spongiosa) must be classified as good. One knee joint had to be stiffened by operation. There were no reactivations within an average followup period of 3 years.

Idiopathic chronic uterine inversion in a nulligravida

A 25-year-old nulligravida presented at this Gynaecology clinic with post coital and intermenstrual bleeding with brownish vaginal discharge dating 8 months. She attained menarche at 18 years of age and since then had normal menstruation until onset of complaints. She had moderate pallor with normal cardiopulmonary status and her abdomen was normal. There was a reddish firm polypoid friable and tender mass measuring 6x4 cm in the vagina which appeared continuous with the cervix but the uterus was not bimanually ballotable. An impression of cervical polyp with anaemia was made to exclude a chronically inverted uterus. She was transfused and had examination under anaesthesia (EUA) and the findings were consistent with idiopathic chronic non-puerperal uterine inversion. The uterus was repositioned using the Haultain’s operation as described below. Her post-operative recovery was satisfactory and she resumed normal menstruation 4 weeks later. (excerpt)

Prolonged conservative treatment or 'early' surgery in sciatica caused by a lumbar disc herniation: rationale and design of a randomized trial [ISRCT 26872154

BackgroundThe design of a randomized multicenter trial is presented on the effectiveness of a prolonged conservative treatment strategy compared with surgery in patients with persisting intense sciatica (lumbosacral radicular syndrome).Methods/designPatients presenting themselves to their general practitioner with disabling sciatica lasting less than twelve weeks are referred to the neurology outpatient department of one of the participating hospitals. After confirmation of the diagnosis and surgical indication MRI scanning is performed. If a distinct disc herniation is discerned which in addition covers the clinically expected site the patient is eligible for randomization. Depending on the outcome of the randomization scheme the patient will either be submitted to prolonged conservative care or surgery. Surgery will be carried out according to the guidelines and between six and twelve weeks after onset of complaints. The experimental therapy consists of a prolonged conservative treatment under supervision of the general practitioner, which may be followed by surgical intervention in case of persisting or progressive disability. The main primary outcome measure is the disease specific disability of daily functioning. Other primary outcome measures are perceived recovery and intensity of legpain. Secondary outcome measures encompass severity of complaints, quality of life, medical consumption, absenteeism, costs and preference. The main research question will be answered at 12 months after randomization. The total follow-up period covers two years.DiscussionEvidence is lacking concerning the optimal treatment of lumbar disc induced sciatica. This pragmatic randomized trial, focusses on the 'timing' of intervention, and will contribute to the decision of the general practictioner and neurologist, regarding referral of patients for surgery.

Idade como fator de risco independente para cefaléias secundárias

To verify if the age is a risk factor for secondary headaches, regardless the time interval since the onset of the headache complaint. 1131 patients were selected, with the main complaint of headache. The ratio of secondary headaches was evaluated and compared between young and elderly patients in general; between individuals with headache starting before and after 60 years of age; and between young and elderly subjects with headache having started for less than one year. Elderly patients in general and individuals with headache having started after 60 years of age presented a higher ratio of secondary headaches than the young subjects and the ones whose pain started before 60 years of age. Elderly subjects with headache of recent start presented a higher ratio of secondary headaches than young individuals with the same time of pain evolution. Age is an independent risk factor for secondary headaches, regardless the time interval since the onset of the complaint.

Adnexal torsion in very young girls: diagnostic pitfalls

Objective: Evaluation of cases of young girls diagnosed with adnexal torsion. Study Design: Retrospective cohort study of 39 girls born between January 1980 and January 2000 who presented with acute abdominal pain and/or the diagnosis adnexal torsion in the Groene Hart Hospital. Seven patients, aged 6–13 years, with adnexal torsion were further evaluated. Results: In three patients, it was possible to save the adnexa. Only the time relapse between the onset of complaints and the surgical intervention correlated with the presence of microscopic necrosis in the ovary. Bluish-black appearance of an ovary did not correlate with the presence of microscopic necrosis. Conclusions: Early recognition and treatment are essential to minimise the risk of decreased fertility after adnexal torsion in young girls. We therefore advocate prompt diagnostic laparoscopy and detorsion of the adnexa. In case a cyst is present, it should not be resected, but checked on a regular basis using ultrasound.

Diagnosis of acute haematogenous osteomyelitis and septic arthritis: 20 years experience at the University Children’s Hospital Basel

Objective: To review the diagnostic experience with acute haematogenous osteomyelitis (AHOM) and/or septic arthritis at our institution.
 Methods: Retrospective review of the medical records of those patients with a bacteriologically and/or radiologically confirmed diagnosis, hospitalised in the University Children's Hospital Basel, Switzerland between January 1980 and July 2000.
 Results: 90 patients (61% males), 4 weeks to 14 years of age, met the inclusion criteria. Median duration of disease prior to hospitalisation was 3 days (range 0-14); 88% were admitted during the first week after onset of complaints. 81 patients received no antimicrobial therapy prior to hospitalisation and are the subject of this presentation. ESR (1st hour in mm; median 36; range 11-124), CRP (mg/l; median 64; range 0-221) and WBC (x 10(9)/l; median 13; range 5-34) were elevated in 100%, 82% and 58% of patients, respectively. Blood cultures (BC) and/or tissue cultures (TC) were performed in 79 (98%) patients. Overall, bacteria were isolated from 53 patients (65%) with Staph. aureus as the most frequent organism (n = 31; 50%). BC were performed in 67 patients and yielded 35 (52%) positive cultures; TC (n = 47) yielded 27 (57%) isolates. In 34 patients with both BC and TC performed, only 12 (35%) were positive in both tests. Diagnostic findings were observed in 23 (59%) of 39 plain radiographs, 31 (56%) of 55 sonograms, 39 (89%) of 44 99mTc-labeled bone scans and 4 (100%) of 4 MRI. 41 patients with diagnostic radiological findings had consecutive TC yielding 30 (73%) bacteriological isolates. Median duration of hospitalisation was 15 days (range 2-66).
 Conclusion: Our data indicate that the diagnostic procedures of choice should be 1) early bone scan or MRI, 2) BC and 3) TC. Of supportive laboratory parameters, ESR and CRP were most valuable in our hands.

Diagnosis of acute haematogenous osteomyelitis and septic arthritis: 20 years experience at the University Children's Hospital Basel.

To review the diagnostic experience with acute haematogenous osteomyelitis (AHOM) and/or septic arthritis at our institution. Retrospective review of the medical records of those patients with a bacteriologically and/or radiologically confirmed diagnosis, hospitalised in the University Children's Hospital Basel, Switzerland between January 1980 and July 2000. 90 patients (61% males), 4 weeks to 14 years of age, met the inclusion criteria. Median duration of disease prior to hospitalisation was 3 days (range 0-14); 88% were admitted during the first week after onset of complaints. 81 patients received no antimicrobial therapy prior to hospitalisation and are the subject of this presentation. ESR (1st hour in mm; median 36; range 11-124), CRP (mg/l; median 64; range 0-221) and WBC (x 10(9)/l; median 13; range 5-34) were elevated in 100%, 82% and 58% of patients, respectively. Blood cultures (BC) and/or tissue cultures (TC) were performed in 79 (98%) patients. Overall, bacteria were isolated from 53 patients (65%) with Staph. aureus as the most frequent organism (n = 31; 50%). BC were performed in 67 patients and yielded 35 (52%) positive cultures; TC (n = 47) yielded 27 (57%) isolates. In 34 patients with both BC and TC performed, only 12 (35%) were positive in both tests. Diagnostic findings were observed in 23 (59%) of 39 plain radiographs, 31 (56%) of 55 sonograms, 39 (89%) of 44 99mTc-labeled bone scans and 4 (100%) of 4 MRI. 41 patients with diagnostic radiological findings had consecutive TC yielding 30 (73%) bacteriological isolates. Median duration of hospitalisation was 15 days (range 2-66). Our data indicate that the diagnostic procedures of choice should be 1) early bone scan or MRI, 2) BC and 3) TC. Of supportive laboratory parameters, ESR and CRP were most valuable in our hands.

Whiplash-type neck distortion in restrained car drivers: frequency, causes and long-term results.

An analysis was made of 1176 whiplash-type neck distortions taken from a total of 3838 restrained car driver incident reports. The percentage of whiplash-type neck distortion among injured drivers increased from less than 10% in 1985 to over 30% in 1997. Most occurred in head-on crashes or crashes with multiple collisions; only 15% occurred in rear-end collisions. More than 1,000 questionnaires were sent to the injured to find out about the duration and type of complaints caused by their cervical spine injury. Although only 138 (12%) returned the questionnaire, which may not be a representative sample, a further analysis was carried out. Of the 138, 121 (88%) indicated that they had suffered or were still suffering from their symptoms. The percentages of the various complaints were as follows: pain (74%), tension (6%) and stiffness (5%) in the head (27%), neck (55%) and shoulder (8%). The duration of the complaints was longest after multiple collisions and when the onset of complaints was longer than 24 h after trauma. Women and elderly persons predominated slightly in the group with longer duration of complaints. A correlation between the severity of the accompanying injuries and duration of complaints was found. Lack of adequate follow-up for patients with less severe injuries posed considerable difficulties for this retrospective study. In order to better evaluate this problem, prospective studies are necessary, with documentation including diagnosis, treatments, complaint duration and type.

Acceleration related injury of the cervical spine in restrained car drivers. Investigations on the trauma mechanism and severity of injury.

The analysis of 1,176 whiplash-type neck distortions was sought from a total of 3,838 restrained car driver incident reports. The percentage of these injuries increased from less than 10 % in 1985 to over 30 % in 1997. These occurred mostly with head-on or with multiple collisions, and only in 15 % with pure rear-end collisions. In 23,2 %, δv amounted 10 km/h or less, which corresponds to a very minor crash. The average δv was the highest in the cases of head-on collisions. Letters were sent to the injured to find out about the duration and type of complaints caused by a cervical spine injury. Of the 138 patients who returned the questionnaires, 121 (88 %) indicated that they had or were still suffering from their symptoms. Percentage of various complaints were as follows: pain (74 %), tension (6 %) and stiffness (5 %) in the head (27 %), neck (55 %) and shoulder (8 %). The duration of the complaints was longest after multiple collisions and when the onset of complaints was later than 24 hours after trauma. Women and elderly persons predominated slightly in the group with longer duration of complaints. A correlation between the severity of the accompanying injuries and duration of complaints occurred. Also, with this retrospective study there was considerable difficulties in the lack of adequate follow-up for these patients with less severe injuries. In order to better evaluate this problem, prospective studies are necessary which include documentation of diagnosis, treatment protocols, duration and type of complaints.

The time span between symptom onset and starting treatment in head and neck tumors

The interval between the onset of symptoms in patients with head and neck cancers and the introduction of treatment was evaluated. During a 1-year period, patients were interviewed to determine the duration of any delays from the onset of complaints until the first visit to a doctor. Also asked was how long it took to be referred to an ENT specialist and actual referral to our department. We then determined the interval from diagnosis to the introduction of therapy. It was found that the delay of patients who went directly to an otorhino-laryngologist was shorter (median, 8 weeks) than that of patients who first went to their family doctors (median, 13 weeks) (P < 0.02). The latter then took an additional 4 weeks before sending patients to an otorhinolaryngologist. Referral from the ENT specialist to our department took another 2 weeks, as well as our staging and pre-therapeutic management. Our findings show that the patient himself is the critical factor in delaying diagnosis and therapy. Tumor patients with greater professional qualification went to their doctors earlier (P < 0.0001) or more often went directly to an ENT specialist (P < 0.002). Consultations of physicians without experience in otorhinolaryngology caused yet further delays.

Silicone breast prostheses and rheumatic symptoms: a retrospective follow up study.

To determine whether women with silicone breast prostheses have more rheumatic complaints than controls. The study included 287 women who had silicone breast prostheses implanted between 1978-90. For every patient a female control of the same age was selected who had had an aesthetic operation in the same year. A questionnaire was sent to this retrospective cohort of women with silicone breast prostheses and controls. Questionnaires were returned by 235 cases (82%) and 210 controls (73%). Patients reported more symptoms arising after surgery than controls (0.6 v 0.3 complaints per subject, p < 0.001). The average interval between surgery and onset of complaints was 5.1 years for patients and 5.9 for controls. Complaints presented by patients were: painful joints (p < 0.005), burning eyes (p < 0.01), and skin abnormalities (p < 0.005). Differences in the use of antirheumatic drugs or medical consultations related to rheumatic symptoms did not reach statistical significance. Further information obtained from the patients and controls reporting rheumatic symptoms did not reveal the presence of a specific syndrome in connection with silicone materials. Women with silicone breast prostheses report more rheumatic complaints after silicone implantation than controls, but there is no evidence of increased prevalence of common rheumatic diseases.

Do patients suffering from obsessions alone differ from other obsessive-compulsives?

The aim of this study was to determine whether a group of 48 patients with obsessions and compulsions differed from a group of 26 patients with obsessions alone, on the basis of demographic variables, variables relating to obsessive-compulsive neurosis, psychological variables and treatment outcome. It was found that they differed significantly in the following areas: marital status, level of education, age at onset of complaints, psychoactive medication taken when admitted for treatment, severity of obsessive-compulsive complaints, depression and intelligence. No difference was found as far as treatment outcome was concerned. Patients suffering from obsessions alone, would appear to form a distinct sub-group within the group of obsessive-compulsive patients as a whole.

Prediction of apical thrombus formation in acute myocardial infarction based on left ventricular spatial flow pattern

The predictive value of the left ventricular spatial flow pattern for thrombus formation was determined in 62 patients with acute myocardial infarction. A normal flow pattern by pulsed Doppler echocardiography was characterized by 1) simultaneous onset of blood motion at the mitral valve and apical level, and 2) a discontinuous Doppler signal along the lateral wall and interventricular septum. The flow pattern was assessed by these criteria, within 24 h after the onset of complaints and after 6 and 12 weeks. In 46 of the 62 patients, a normal flow pattern was found at the first examination; none of these 46 patients developed a thrombus during the study period. An abnormal flow pattern was seen at the first examination in 16 patients; this pattern normalized during follow-up in 6 patients, none of whom developed a thrombus. In the other 10 patients the abnormal flow pattern persisted, and 7 of these developed a thrombus. These findings suggest that a normal left ventricular flow pattern in the setting of acute myocardial infarction is not associated with subsequent thrombus formation. This observation may be of importance if anticoagulation is considered.