Can a clinical score aid in early diagnosis and treatment of various stroke syndromes?

BACKGROUND: Accurate and timely diagnosis of hemorrhagic and nonhemorrhagic strokes helps in patient management. Neuroimaging studies are useful in diagnosis and distinction of hemorrhagic (HS) and nonhemorrhagic (NHS) strokes. The use of clinical variables, such as Siriraj stroke scores (SSS), has shown good sensitivity, specificity and predictive values (distinguishing stroke types). The aim of our study was to evaluate the use of SSS in a U.S. population and assess whether it could aid to expedite treatment decisions. METHODS: Levels of consciousness, vomiting, headache and atheroma markers used in SSS were applied to patients who met the criteria for stroke. RESULTS: Of the 302 patients identified, the SSS classified 254 with sensitivity of 36% (HS) and 90% (NHS) and positive predictive values of 77% and 61%, respectively. CONCLUSION: Our results suggest that SSS is not reliable in distinguishing stroke types (in a US population). Definite neuroimaging studies are needed prior to thrombolytic therapy.

Modified barium swallow does not affect how often PEGs are placed after stroke.

Dysphagia frequently follows stroke, but often resolves quickly. Percutaneous endoscopic gastrostomy (PEG) or other feeding tubes are placed to improve nutrition and hydration, and reduce the risk of aspiration pneumonitis. We evaluated the impact of modified barium swallow in determining PEG placements and the influence of specific swallowing abnormalities on PEG placement. The abnormalities assessed were presence of pharyngeal stasis and/or visualization of posterior pharyngeal transfer problems and aspiration of liquid or solids. A total of 302 patients with stroke were admitted to our hospital between 1989 and 1993, but only those with hemorrhagic or nonhemorrhagic stroke by computed tomographic (CT) scans or magnetic resonance imaging (MRI) or autopsy were included in our study. Patients with transient ischemic attacks (TIAs), central nervous system tumors, and traumas were excluded. Barium swallow studies were performed on 69 (23%) of patients; 49 (71%) were abnormal, based on aspiration of barium, pharyngeal stasis, or postpharyngeal transfer dysphagia. PEGs were placed in only 18% of those with abnormal studies. Of the patients with normal barium swallow studies, 25% had a PEG placed. Two hundred thirty-three patients underwent no barium swallow studies, but 11 (4.72%) of these had PEG placed. The rate of PEG placement was not related to any one of the abnormalities noted on the modified barium swallow. Rather, patients who received PEG had significant neurological deficits and increased prevalence of aspiration pneumonitis. The decision to insert PEG was made on clinical grounds and not on abnormal barium studies alone.

Secondary hypertension: evaluation and treatment.

Most patients with hypertension in the United States have essential (primary) hypertension (95%), the cause of which is unknown. The remaining 5% of adults with hypertension have the secondary form of hypertension, the cause and pathophysiologic process of which are known. Internists and other primary care physicians refer to this as treatable or curable hypertension, because the hypertension can be managed or even controlled with medications. Similarly, the condition is called surgical hypertension by surgeons in the belief that once the cause is determined and identified, surgical intervention will result in cure of hypertension. Secondary causes of hypertension include renal parenchymal disease, renovascular diseases, coarctation of the aorta, Cushing's syndrome, primary hyperaldosteronism, pheochromocytoma, hyperthyroidism, and hyperparathyroidism. Occasionally included in this category are alcohol- and oral contraceptive-induced hypertension and hypothyroidism, but these conditions are not discussed herein. The evaluation of secondary hypertension is of interest and can bring together different facets of anatomy, physiology, pharmacology, and radiology in the medical and surgical treatment of these disorders. Despite enthusiasm that can be generated in the evaluation of these conditions, evaluation can be expensive and should not be conducted for all patients with hypertension. Features that aid in the diagnosis of secondary hypertension include the following: 1. Onset of hypertension before the age of 20 or after the age of 50 years. The presence of hypertension at a young age may suggest coarctation of the aorta, fibromuscular dysplasia, or an endocrine disorder. Hypertension found for the first time after the age of 50 years may suggest the presence of renovascular hypertension caused by atherosclerosis. 2. Markedly elevated blood pressure or hypertension with severe end-organ damage, as in grade III or IV retinopathy. These findings suggest the presence of renovascular hypertension or pheochromocytoma. 3. Specific body habitus and ancillary physical findings. For example, truncal obesity and purple striae occur with hypercortisolism, and exophthalmos is associated with hyperthyroidism. 4. Resistant or refractory hypertension (poor response to medical therapy usually necessitating use of more than three antihypertensive medications from three different classes). 5. Specific biochemical test that suggest the existence of certain disorders, such as hypercalcemia in hyperparathyroidism, hyperglycemia in Cushing's syndrome and pheochromocytoma, and unprovoked hypokalemia with renin-producing tumors, primary hyperaldosteronism, or renin-mediated renovascular hypertension. 6. Other characteristics that may suggest secondary hypertension such as abdominal diastolic bruits (renovascular hypertension), decreased femoral pulses (coarctation of the aorta), or bitemporal hemianopias (Cushing's disease). A combination of a good history and physical examination, astute observation, and accurate interpretation of available data usually are helpful in the diagnosis of a specific causation.

Subcutaneous sumatriptan for treatment of acute migraine in patients admitted to the emergency department: a multicenter study.

STUDY OBJECTIVE: To assess the efficacy of SC sumatriptan injection versus placebo in the treatment of acute migraine in ED patients and that of open-label 100 mg sumatriptan PO tablets for recurrent migraine. DESIGN: Randomized, double-blind, placebo-controlled, multi-center trial. SETTING: Twelve EDs in the United States. PARTICIPANTS: Adult patients presenting to the ED from September 1992 through April 1993 with a diagnosis of migraine as determined by International Headache Society criteria. Patients were randomized to receive 6 mg sumatriptan SC or placebo. Patients were monitored for improvement in headache severity using a four-point scale and for time to meaningful relief using a stopwatch. The time to discharge from the ED was recorded. An open-label 100 mg sumatriptan PO tablet was given to all patients on discharge from the ED for use at home if the headache recurred within 24 hours. RESULTS: One hundred thirty-six patients were enrolled. Seventy-five percent of patients treated with sumatriptan achieved meaningful relief compared with 35% treated with placebo (P < .001). The median time to meaningful relief was 34 minutes in the group that received sumatriptan. Seventy percent of patients in the sumatriptan group versus 35% in the placebo group reported mild or no pain at discharge (P < .001). Migraine-associated symptoms such as nausea, photophobia, and phonophobia were significantly reduced in the sumatriptan group (P < .005). The median time to discharge from the ED was shorter for the sumatriptan group than for the placebo group (60 versus 96 minutes, respectively; P = .001). At baseline, 15% of patients in the sumatriptan group and 19% of patients in the placebo group reported mild or no clinical disability. At the time of discharge, patients with mild or no disability increased to 75% in the sumatriptan group compared with 44% in the placebo group (P = .001). Fifty-seven of 92 patients (62%) with mild or no pain at discharge took open-label oral sumatriptan for headache recurrence, and 37 (65%) experienced meaningful relief within 2 hours. Median time to meaningful relief after oral sumatriptan was 65 minutes. CONCLUSION: Sumatriptan (6 mg SC) is effective in treating acute migraine in the ED. Oral sumatriptan (100 mg) is effective in treating headache recurrence within 24 hours.

Routine prolactin measurement is not necessary in the initial evaluation of male impotence.

The authors determined the prevalence of hyperprolactinemia in impotent men in a community setting and assessed the cost of case detection with routine estimation of serum prolactin. They recruited 299 consecutive patients with impotence and determined the hormonal levels (prolactin, luteinizing hormone, follicle-stimulating hormone, and testosterone). Pituitary gland imaging was done when the prolactin level was elevated. Simultaneous prolactin and testosterone levels were available for 212 patients. Three patients (1.4%) had elevated prolactin levels but none had pituitary tumor. Two of these had low testosterone levels. Overall, 51 patients (24.1%) had low testosterone levels. Cost of selective prolactin estimation in patients with low testosterone levels resulted in a net saving of $2,574 per case detected. The authors conclude that the prevalence of hyperprolactinemia in impotence is low. Routine measurement of prolactin levels in impotence is not indicated. Selective determination in patients with low testosterone reduces the cost of diagnostic evaluation.

Enhancing faculty participation and interest in quality improvement in academic centers.

Continuous quality improvement (CQI) is necessary in maintaining and improving the quality of medical care delivered. However, quality assurance (QA) in the past was performed superficially to meet requirements of the Joint Commission on Accreditation of Health Care Organizations and other regulatory agencies. Academic faculty participation in QA activity was also limited. Faculty often assume that meaningful quality process demands excessive efforts and time unrewarded with career advancement, promotion, or monetary compensation. In addition, unstructured QA leads to duplication of data and loss of educational opportunity. We reorganized the QA process in internal medicine using the CQI concept to: (a) improve academic faculty participation, (b) incorporate educational concepts, (c) stimulate interest in outcome research and CQI, and (d) integrate cost containment. A reorganized CQI format has stimulated enthusiastic participation of faculty and residents, and has generated conferences and grand rounds pertinent to medical care, outcome research, and cost containment. We conclude that academic faculty should play leadership roles in the CQI process and include teaching models. Improved and increased academic faculty participation could be realized, when educational values, research activities, and cost analysis are incorporated into the CQI process.

Zygomycosis mimicking paranasal malignancy.

A case of zygomycosis involving the maxillary sinus in a normal host and mimicking paranasal malignancy is presented. Computed tomographic images showing destruction of adjoining bony structures and histologic features of fungi are described and presented. A successful outcome was achieved with amphotericin B irrigation and parenteral amphotericin B. Nasal biopsy should be advised by both radiologists and clinicians in all cases of lesions that look like malignancy in the sinus areas before a treatment modality is initiated.

Sexual headaches: case report, review, and treatment with calcium blocker.

A case is reported in which a patient with sexual and orgasmic headaches was treated successfully with a calcium channel blocker, diltiazem. To the best of our knowledge, this is the first case of successful treatment of sexual headaches with calcium channel blockers reported in the English medical literature. The literature on sexually related headaches is reviewed, and classification, evaluation, differential diagnosis, pathophysiology, differential diagnosis, and treatment of sexual headaches are discussed.