Etiology and diagnosis of bilateral leg edema in primary care.

PURPOSE: To identify the causes of bilateral leg edema in a primary care setting, and to determine the ability of primary care providers to arrive at the correct diagnosis using the information available at the initial clinical encounter. PATIENTS AND METHODS: Fifty-eight ambulatory adult patients with bilateral leg edema were enrolled at an inner city family practice during a 3-year period. Historical information, physical examination findings, and clinical impressions of primary care providers were compared with the results of laboratory evaluations consisting of echocardiograms, venous duplex ultrasound leg scans, serum albumin levels, and when appropriate, 24-hour urinalyses. RESULTS: Forty-five patients (78%) completed the study. The initial clinical impression was venous insufficiency in 32 (71%) patients and congestive heart failure in 8 (18%) patients. In actuality, 15 (33%) patients had a cardiac condition as a cause of their leg edema, and 19 (42%) had pulmonary hypertension. All of the patients with heart disease, and almost all of those with pulmonary hypertension, were age 45 years or older. Only 10 (22%) of the subjects had venous insufficiency. Renal conditions, medication use, and hypoalbuminemia were less common. CONCLUSIONS: Utilizing clinical information only, many patients with cardiopulmonary pathology were incorrectly diagnosed as having more benign conditions, most commonly venous insufficiency. Echocardiographic evaluation, including an estimation of pulmonary artery pressure, may be advisable in many patients with bilateral leg edema, especially if they are at least 45 years old.

Unicameral bone cyst of the first metatarsal.

An unusual case of a unicameral bone cyst located in the head of the first metatarsal is presented with a review of the literature. This benign bone tumor is rarely found in the metatarsal bones. Pathologic, clinical, and radiographic findings, as well as a differential diagnosis will be discussed.

Urinary 3-methylhistidine excretion in man: the role of protein-bound and soluble 3-methylhistidine.

The influence of dietary meat and meat stock intake on urinary excretion of 3-methylhistidine (3MH) was examined in human adults. In the absence of 3MH ingestion for 48 h, the study subjects adjusted to an intrinsic urinary 3MH: creatinine value. If the meat and meat stock-free diet was maintained on subsequent days, only minute diurnal variations occurred, and the values of random urine samples during the day were representative of the 24 h 3MH: creatinine value. The mean 3MH: creatinine value (SD) for a group of adults (n 7) was 0.105 +/- 0.023 (mumol of 3MH/mg creatinine), which is approximately 35% lower than the corresponding value in healthy growing infants (0.148 +/- 0.039) (Seashore et al. 1981). Ingestion of meat soup and meat causes different patterns of urinary excretion of 3MH which are consistent with the finding that meat extracts, such as soup and stock, contain considerable amounts of 3MH. The 3MH contents of beef, chicken and turkey were 3.8 +/- 0.15, 3.0 +/- 0.09 and 2.3 +/- 0.29 mumol/g dry wt meat respectively. All three meats contained a water-soluble 3MH-fraction (% total 3MH: beef 8, chicken 21, turkey 23). Amino acid analysis of the soluble fraction with or without hydrochloric acid hydrolysis demonstrated free 3MH in chicken and turkey (5.2 and 2.8% of the total respectively) but not in beef. Patients undergoing urinary 3MH measurements should maintain a diet that is free not only of solid meats, but also of meat stock. The ingestion of commercial food products (e.g. frozen or canned meals, sauces, pizza, etc.) may impair the validity of such measurements because of their meat-stock content. A dietary regimen is presented which is based on a shorter 12 h urine collection. The shorter collection time is satisfactory in the light of the steady rate of 3MH-excretion after 2 d of a diet free of meat and meat stock.