Pain Of Unknown Cause Research Articles

CLINICAL, MAGNETIC RESONANCE, AND SONOGRAPHIC IMAGING FINDINGS IN HORSES WITH PROXIMAL PLANTAR METATARSAL PAIN

Sonography is commonly used for diagnosis of desmopathy of the proximal part of the suspensory ligament in horses. However, magnetic resonance (MR) imaging has been stated to be superior for detecting disease and localizing lesions. In this retrospective study of 39 horses or 46 hind limbs with lameness due to proximal plantar metatarsal pain, the clinical and diagnostic findings are discussed and sonography and MR imaging compared for examination of the proximal part of the suspensory ligament. With MR imaging interpreted as the clinical gold standard, desmopathy of the proximal part of the suspensory ligament was diagnosed in 21 hind limbs, proximal plantar metatarsal pain of unknown cause in 12, an osseous injury at the origin of the suspensory ligament in four and a condition unrelated to the suspensory ligament in nine. Based on these findings, sonography had a sensitivity of 0.77 and 0.66 and specificity of 0.33 and 0.31 for diagnosing proximal suspensory desmopathy and for accurately localizing lesions, respectively. MR imaging changes consistent with proximal suspensory desmopathy were signal hyperintensities and an increase in cross-sectional area compared with the contralateral limb. Anesthesia of the deep branch of the lateral plantar nerve is not specific neither for proximal suspensory desmopathy, as conditions unrelated to the suspensory ligament were diagnosed, nor for diagnosis of proximal plantar metatarsal pain, as conditions outside the proximal plantar metatarsal region were also diagnosed.

Diagnosis of Radio-Occult Pulmonary Conditions by Real-Time Chest Ultrasonography in Patients with Pleuritic Pain

The evaluation of pleuritic pain in the emergency department (ED) presents a considerable challenge for the attending physician. Chest radiography (CXR) is a basic test, but its sensitivity is low, and often more sophisticated imaging techniques are needed. Our aim is to assess the diagnostic value of bedside B-mode lung ultrasound (LUS) in the visualization of radio-occult pulmonary lesions. Forty-nine patients complaining of pleuritic pain with negative CXR were prospectively studied by LUS. Detection of at least one of the following sonographic signs in the painful thoracic area was considered diagnostic: (i) the absence of pleural sliding; (ii) the focal alveolar-interstitial syndrome (AIS), defined by multiple artifacts B-line; (iii) the peripheral alveolar consolidation (PAC), defined by hypoechoic subpleural images; and (iv) the pleural disruption with thickening and irregularity of the line, with or without localized effusion. The final diagnoses were confirmed by spiral CT scanning ( n = 12) and follow-up ( n = 37). Final diagnoses were chest wall pain ( n = 30), pleuropneumonia ( n = 14), pulmonary embolism ( n = 4), lung metastasis ( n = 1). In 18 patients of the group with pulmonary conditions, LUS showed signs of pleurisy. They were PAC ( n = 12), AIS ( n = 17), pleural disruption ( n = 17). If any sign is considered, the sensitivity of LUS in the diagnosis of radio-occult lesions was 94.7%, specificity was 96.7%, positive and negative predictive values were 94.7% and 96.7%, respectively, and accuracy was 95.9%. In patients with pleuritic pain of unknown cause, real-time LUS enables the diagnosis of radio-occult lung and pleural lesions. (E-mail: gio.volpicelli@tin.it)

Evaluation of early abdominopelvic computed tomography in patients with acute abdominal pain of unknown cause: prospective randomised study

Objectives: To evaluate the impact of early abdominopelvic computed tomography in patients with acute abdominal pain of unknown cause on length of hospital stay and accuracy of diagnosis.Design: Randomised, prospective...

Prospective audit of incidence of prognostically important myocardial damage in patients discharged from emergency department.

Objective: To assess the incidence of prognostically important myocardial damage in patients with chest pain discharged from the emergency department.Design: Prospective observational study.Setting: District general hospital emergency department.Participants: 110 patients...

Factitious disease of periocular and facial skin

PURPOSE: To describe the clinical appearance of factitious (or self-inflicted) lesions on periocular skin and face.METHODS: All patients with factitious cutaneous disease who were examined at Mayo Clinic, Rochester, Minnesota, between 1985 and 1997 were identified. For patients with lesions on the face and periocular skin, the demographic features, clinical descriptive characteristics of their lesions, associated psychopathology, and treatments were ascertained.RESULTS: Of 38 patients with factitious dermatitis, 18 (47%) had facial lesions. Of these 18 patients, 15 (83%) were female. The mean age (± SD) of the patients with facial lesions was 35.2 ± 15.7 years (range, 9 to 66 years). Eight patients (44%) had neurotic excoriations, nine (50%) had dermatitis artefacta, and one (6%) had trichotillomania. The working diagnoses of five patients cared for initially in the Department of Ophthalmology were corneal epithelial and facial desquamation associated with severe pain of unknown cause, medial cicatricial ectropion of probable vasculitic cause, basal cell carcinoma of the nasojugal fold, recurrent preseptal cellulitis resistant to medical treatment, and madarosis of the upper eyelids of unknown cause.CONCLUSION: Cutaneous factitious disease may masquerade as numerous clinical entities and should be included in the differential diagnosis of lesions of the periocular skin.

Glenohumeral ligaments and shoulder capsular mechanism: evaluation with MR arthrography.

To evaluate the efficacy of magnetic resonance (MR) arthrography in identification of the glenohumeral ligaments (GHLs) and to determine the location of abnormalities of the GHL, joint capsule, and labrum. MR arthrograms were evaluated retrospectively in 46 patients with a history of shoulder instability, impingement syndrome, or pain of unknown cause. Imaging findings were correlated with surgical observations. The superior, middle, and inferior GHLs were identified on MR arthrograms in 39 (85%), 39 (85%), and 42 (91%) of the 46 patients, respectively. In diagnosis of tears of the superior, middle, and inferior GHLs, MR arthrography had a sensitivity of 100%, 89%, and 88% and a specificity of 94%, 88%, and 100%, respectively. Findings at MR arthrography can help accurate identification and demonstration of the integrity of the GHL and labrum and can help in staging of abnormalities. The large number of abnormalities depicted in the middle and inferior GHLs suggests that both might be important in the maintenance of glenohumeral joint congruity.

Medical oxymorons can be pretty ugly.

In 1 986, Warren S. Blumenfeld, a professor at Georgia State University, published an obscure book [2] that attracted widespread attention among those with an acute interest in the obtuse. It was entitled: Jumbo Shrimp and Other Almost Perfect Oxymorons. A few examples from his book reveal the oxymoron’s real potential for serious satire: criminal justice, political scientist, graduate student, rock music, light opera, live television, military intelligence, civil wan, legal brief, statistical significance, casual sex. Since reading Professor Blumenfeld’s book, I have noticed examples of the oxymoron lurking conspicuously in nadiologic publications. These have resulted, sadly, in unintended humor and have cleanly confused the reading audience. Here are some examples: “Absence of breath sounds was present” (or “Presence of breath sounds was absent”). “Absence...present” and “Presence...absent” are models of the type of oxymoron to avoid. In short, they serve only to lengthen the sentence. Suggestion: “Breath sounds were absent.” “The patient had a diagnosis of undiagnosed abdominal pain How can a diagnosis be undiagnosed? This construction is another excellent example of a terrible oxymoron. Suggestion: “The patient had abdominal pain of unknown cause.” “Causes of epigastnic pain include peptic ulcer, hiatal hernia, cholecystitis, and idiopathic.” Because idiopathic means “of unknown cause,” listing idiopathic as a cause is almost identical (perhaps even exactly similar) to saying that the patient has a diagnosis of undiagnosed pain. Suggestion: “Causes of epigastric pain include peptic ulcer, hiatal hernia, and cholecystitis. In some patients, the cause is never determined.” “1311-Hippuran showed no visualization of the kidneys.” This construction (“showed no visualization”) is obviously a subtle oxymoron (the tracer showed something that was not shown). Suggestion: “Renal uptake of 131l-Hippuran was absent.” ‘This represents a nonmnflammatory arthritis.” Arthritis comes from the Greek arthron = a joint, and -itis (suffix) = inflammation. A noninflammatory inflammation is cleanly confusing. Suggestion: ‘This is a noninflammatory arthnopathy.” A typical variant of the oxymoron is the following: ‘The results of pulmonary function tests in our patient were nonmal. The only abnormality was decreased diffusing capacity.” Having just explicitly implied that the test results were normal, the author states the exact opposite. Suggestion: “The only abnormal result of pulmonary function tests in our patient was “These findings were also present in several normal patients.” Care should be exercised in juxtaposing “normal” and “patients.” Patients normally have abnormalities that constitute ill health, even though the abnormalities may appear to the blinded observer to lie on a normal distribution curve. In general, it is always better to use the term “healthy subjects.” “Discussion was centered around the relative merits of MRI and CT myelognaphy.” Scattered occurrences of the term “centered around” are ubiquitous in the radiologic litenatune, despite the fact that this term does not square with the properties of the circle as described by the principles of practical Euclidean geometry. The center (from Greek: kentron = sharp point) is the point about which a circle’s cincumfenence is drawn. To write on say “centered around” is to confuse the center with the circumference. This is another variant of the oxymoron, and a pretty ugly one at that. Suggestion: “centered on.” The oxymoron, particularly the unintended oxymoron, detracts from scientific writing. Because the oxymoron involves intimate juxtaposition of two widely disparate concepts, it may definitely confuse casual readers who are scrutinizing what you have written. Deliberately avoid the oxymoron, particularly the unintended oxymoron, unless you have a confident suspicion that the reader knows exactly what you think you mean.

Dynamic bone imaging in the investigation of local bone pathology — When is it useful?

The aim of this work was to establish when, in the investigation of local musculoskeletal symptoms, dynamic isotope bone imaging yields useful information not available from static isotope bone imaging, using 99mTc methylene diphosphonate. One hundred and forty-two dynamic bone scans were reviewed, with particular reference to the site being imaged, the suspected underlying pathology, and the contribution of the dynamic phases to diagnosis, management, and eventual outcome. All were performed as part of the investigation of adult patients complaining of localized musculoskeletal symptoms. The dynamic phases influenced diagnosis, management, and eventual outcome most positively in suspected infection, particularly at a previous fracture site or around a prosthesis. They did not alter management significantly in suspected fracture, avascular necrosis, in most patients with pain of unknown cause, and were rarely helpful in imaging the axial skeleton. We suggest that, in the context of routine bone imaging, dynamic bone scanning should be reserved for cases of suspected infection. In the investigation of most other local bone pathologies, the static phase of the bone scan provides all the diagnostic information which is required for management decisions.

Rupture of the labra acetabularis as a cause of hip pain detected arthroscopically, and partial limbectomy for successful pain relief

We describe two patients who had pain of unknown cause in the right hip for many years. Plain roentgenograms results were normal, and arthrography did not reveal any abnormal findings. Because clinical examinations strongly suggested internal derangement of the hip, arthroscopies of the hips were performed. The labra acetabularis were observed to be ruptured at the posterior margin of the acetabulum. Partial limbectomies were performed by the posterior approach, and the patients showed marked decrease in hip pain postoperatively. This report shows that a solitary lesion of fibrocartilaginous tissue of the hip can cause hip pain. These conditions can be easily misdiagnosed as sciatica.

Role of radionuclide imaging in the evaluation of wrist pain

The cause of hand and wrist pain can be difficult to determine, especially when standard radiographs are normal or show only nonspecific changes. This study reports the effectiveness of radionuclide imaging in the evaluation of patients with hand and wrist pain of uncertain cause. Eighty-eight patients with hand and wrist pain and initially normal standard radiographs were evaluated prospectively by additional radiographic methods including the following: routine tomography, wrist arthrography, computerized tomography, or magnetic resonance imaging. Each patient also had bone scintigraphy. The diagnosis established by clinical assessment and by other imaging methods was then compared with the scintigraphic findings. The presence or absence of focal scintigraphic abnormalities correlated with the presence or absence of focal pathology definable by the conventional methods in 88% of patients. As expected, scintigraphy was chiefly of value in defining the locus of an injury or other process in the wrist, rather than the nature of an abnormality. The scintigrams were abnormal in 95% of cases involving complete intrinsic ligament ruptures and fractures and were normal in 96% of patients with no definable injury. Scintigraphic findings correlated poorly with partial intrinsic ligament injuries and in cases of synovitis. Radionuclide imaging is a sensitive means of detecting focal lesions in patients with hand and wrist pain of unknown cause.

Imaging of femur head necrosis using MR tomography

Magnetic resonance tomography (MR) was used to examine the femoral heads of 20 normals and of 56 patients with diseases of the femoral head, including Perthe's disease (four cases), adult necrosis of the femoral head (39 cases) and pain of unknown cause (13 cases). Femoral head necrosis and Perthe's disease regularly produce reduced signal intensity. The localisation of the areas of necrosis can be determined accurately in the coronary and sagittal plane. In 11 femoral heads, necrosis could be demonstrated unequivocally by MR in the presence of normal radiographic findings. Follow-up of nine patients with negative MR findings and indefinite symptoms confirmed the absence of necrosis.

Oral prodromal signs of a central nervous system malignant neoplasm—glioblastoma multiforme: report of case

A fatal case of glioblastoma multiforme, initially appearing as orofacial pain of unknown cause, is reported. The report of case illustrates the multidisciplinary approach that, at times, is required to diagnose elusive orofacial pain.

Intramuscular Pressure, Muscle Blood Flow, and Skeletal Muscle Metabolism in Chronic Anterior Tibial Compartment Syndrome

One hundred eight patients with lower leg pain of unknown cause underwent intramuscular pressure measurements by the wick technique. Fifteen patients (14%) were found to have a chronic anterior tibial compartment syndrome. In these patients the intramuscular pressure was significantly increased at rest and during and after exercise as compared with normal subjects. The pressure increase after exercise was long-lasting (40 minutes). Biopsies of the anterior tibial muscles showed increased water content, which may explain the elevated pressures. Muscle blood flow during exercise as measured by the xenon-133 clearance technique was decreased, and muscle lactate concentration was increased in the anterior tibial muscles. Fasciotomy relieved pain and normalized intramuscular pressure, muscle blood flow, and skeletal muscle metabolism.

The Pharmacologic Approach in Differential Diagnosis of Chronic Pain

Chronic pain of unknown cause below waist level was evaluated in 100 patients by using the Differential Spinal Block (DSB) in a multidisciplinary pain clinic setting. The classic DSB approach, refined for better control of psychologic variables, was found to be a safe and effective means of differentiating various pain mechanisms. We found that, of all patients tested, 55% had pain of central or psychogenic origin and 30% had sympathetically mediated pain, as compared with 15% who had somatic pain. A long-term follow-up of these patients confirmed this impression. These results substantiated the importance of psychologic variables, in dicating the necessity for use of behavioral-based therapies in conjunction with the routine use of the refined diagnostic DSB procedure in patients with chronic pain.

Appendicitis

One thousand cases of appendicitis seen from 1963 to 1973 were reviewed. The overall negative appendectomy rate was 20%, but in women between ages 20 and 40 it exceeded 40%. Two thirds of the negative appendectomies were due to nonsurgical lesions. Mesenteric adenitis, gastroenteritis, and abdominal pain of unknown cause accounted for one third of the errors in females and two thirds in males. These diseases were best distinguished from appendicitis on the basis of temperature and white blood cell count. The remainder of the errors in females were due to pelvic inflammatory disease or other gynecologic diagnosis and were best distinguished from appendicitis on the basis of history and physical findings. The rate of perforation was 21% overall. The incidence of wound infection was 8.5%. Use of systemic antibiotics did not affect the wound infection rate.