1/6. Internal orbital fractures in the pediatric age group: characterization and management.OBJECTIVE: To evaluate the specific characteristics and management of internal orbital fractures in the pediatric population. DESIGN: Retrospective observational case series. PARTICIPANTS: Thirty-four pediatric patients between the ages of 1 and 18 years with internal orbital ("blowout") fractures. methods: Records of pediatric patients presenting with internal orbital fractures over a 5-year period were reviewed, including detailed preoperative and postoperative evaluations, surgical management, and medical management. MAIN OUTCOME MEASURES: Ocular motility restriction, enophthalmos, nausea and vomiting, and postoperative complications. RESULTS: Floor fractures were by far the most common fracture type (71%). Eleven of 34 patients required surgical intervention for ocular motility restriction. Eight were trapdoor-type fractures with soft-tissue incarceration; five had nausea and vomiting. Early surgical intervention (<2 weeks) resulted in a more complete return of ocular motility compared with the late intervention group. CONCLUSIONS: Trapdoor-type fractures, usually involving the orbital floor, are common in the pediatric age group. These fractures may be small with minimal soft-tissue incarceration, making the findings on computed tomography scans quite subtle at times. Marked motility restriction and nausea/vomiting should alert the physician to the possibility of a trapdoor-type fracture and the need for prompt surgical intervention.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/6. zollinger-ellison syndrome. Clinical presentation in 261 patients.We prospectively evaluated the initial presenting symptoms in 261 patients with zollinger-ellison syndrome (ZES) over a 25-year period. Twenty-two percent of the patients had multiple endocrine neoplasia-type 1 (men-1) with ZES. Mean age at onset was 41.1 /- 0.7 years, with men-1 patients presenting at a younger age than those with sporadic ZES (p < 0.0001). Three percent of the patients had onset of the disease < age 20 years, and 7% > 60 years. A mean delay to diagnosis of 5.2 /- 0.4 years occurred in all patients. A shorter duration of symptoms was noted in female patients and in patients with liver metastases. abdominal pain and diarrhea were the most common symptoms, present in 75% and 73% of patients, respectively. heartburn and weight loss, which were uncommonly reported in early series, were present in 44% and 17% of patients, respectively. Gastrointestinal bleeding was the initial presentation in a quarter of the patients. patients rarely presented with only 1 symptom (11%); pain and diarrhea was the most frequent combination, occurring in 55% of patients. An important presenting sign that should suggest ZES is prominent gastric body folds, which were noted on endoscopy in 94% of patients; however, esophageal stricture and duodenal or pyloric scarring, reported in numerous case reports, were noted in only 4%-10%. patients with men-1 presented less frequently with pain and bleeding and more frequently with nephrolithiasis. Comparing the clinical presentation before the introduction of histamine H2-receptor antagonists (pre-1980, n = 36), after the introduction of histamine H2-receptor antagonists (1981-1989, n = 118), and after the introduction of proton pump inhibitors (PPIs) (> 1990, n = 106) demonstrates no change in age of onset; delay in diagnosis; frequency of pain, diarrhea, weight loss; or frequency of complications of severe peptic disease (bleeding, perforations, esophageal strictures, pyloric scarring). Since the introduction of histamine H2-receptor antagonists, fewer patients had a previous history of gastric acid-reducing surgery or total gastrectomy. Only 1 patient evaluated after 1980 had a total gastrectomy, and this was done in 1977. The location of the primary tumor in general had a minimal effect on the clinical presentation, causing no effect on the age at presentation, delay in diagnosis, frequency of nephrolithiasis, or severity of disease (strictures, perforations, peptic ulcers, pyloric scarring). Disease extent had a minimal effect on symptoms, with only bleeding being more frequent in patients with localized disease. patients with advanced disease presented at a later age and with a shorter disease history (p = 0.001), were less likely to have men-1 (p = 0.0087), and tended to have diarrhea more frequently (p = 0.079). A correct diagnosis of ZES was made by the referring physician initially in only 3% of the patients. The most common misdiagnosis made were idiopathic peptic ulcer disease (71%), idiopathic gastroesophageal reflux disease (GERD) (7%), and chronic idiopathic diarrhea (7%). Other less common misdiagnosis were crohn disease (2%) and various diarrhea diseases (celiac sprue [3%], irritable bowel syndrome [3%], infectious diarrhea [2%], and lactose intolerance [1%]). Other medical disorders were present in 55% of all patients; patients with sporadic disease had fewer other medical disorders than patients with men-1 (45% versus 90%, p < 0.00001). hyperparathyroidism and a previous history of kidney stones were significantly more frequent in patients with men-1 than in those with sporadic ZES. Pulmonary disorders and other malignancies were also more common in patients with men-1. These results demonstrate that abdominal pain, diarrhea, and heartburn are the most common presenting symptoms in ZES and that heartburn and diarrhea are more common than previously reported. The presence of weight loss especially with abdominal pain, diarrhea, or heartburn is an important clue suggesting the presence of gastrinoma. The presence of prominent gastric body folds, a clinical sign that has not been appreciated, is another important clue to the diagnosis of ZES. patients with men-1 presented at an earlier age; however, in general, the initial symptoms were similar to patients without men-1. gastrinoma extent and location have minimal effects on the clinical presentation. overall, neither the introduction of successful antisecretory therapy nor widespread publication about ZES, attempting to increase awareness, has shortened the delay in diagnosis or reduced the incidence of patients presenting with peptic complications. The introduction of successful antisecretory therapy, however, has dramatically decreased the rate of surgery in controlling the acid secretion and likely led to patients presenting with less severe symptoms and fewer complications. (ABSTRACT TRUNCATED)- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/6. Complications of the Angelchik antireflux prosthesis.Various complications have been reported recently for the Angelchik antireflux prosthesis, a silicone-gel prosthesis used in the treatment of gastroesophageal reflux and associated hiatal hernia. We have studied the cases of 11 patients with complications of this prosthesis and have reviewed the literature for others. Complications included 8 erosions of the device into the gastrointestinal tract, 1 migration, 1 improper placement, and 1 case believed to be surgical trauma. These complications represent those typical to reflux surgery and some unique to the Angelchik prosthesis (migration and erosion). The exact frequency is unknown, with the manufacturer estimating migration at 0.81% and erosion at 0.15%. Available data indicate that complications may occur up to several years after implantation, and physicians may not recognize the problems with the prosthesis if they are unaware of the complications.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/6. Functional use of secondary cancer symptomatology.This article presents several case studies which illustrate the way in which a terminal patient's attention may be diverted from the primary disease process, cancer, to secondary somatic symptomatology such as pain and nausea. This phenomenon has important consequences for the patient, family, physician, and the patient's medical treatment. These consequences are discussed in terms of primary gain, tertiary gain, and the "medicalization of existential problems."- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/6. Shunt dysfunction and constipation: could there be a link?A ventriculoperitoneal (VP) shunt is the treatment of choice for hydrocephalus, functioning by means of a pressure differential between the ventricular system and peritoneal cavity. constipation is frequently a concomitant problem in children with VP shunts. A case study is reported in which signs and symptoms of shunt dysfunction appear to have developed as a result of constipation. nurses and physicians must address the need for preventing constipation much more aggressively in the population requiring shunts.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/6. Gastric syphilis.A sexually transmitted disease is seldom considered in the differential diagnosis of patients with clinical gastritis. A patient with gastric syphilis is reported to alert emergency department physicians to this entity. history and physical findings of syphilis should be sought and rapid plasma reagin tests should be obtained in the patient with severe or refractory gastritis.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |