Hyperlipidemia. When does treatment make a difference?

A high serum cholesterol level is regarded as a major contributor to the development of coronary atherosclerosis. Screening for hyperlipidemia should begin no later than age 35 for men and age 45 for women. Individuals with additional risk factors for coronary artery disease should be screened earlier. When values are not within a desirable range, further assessment should be done by determining high-density lipoprotein and triglyceride levels. The initial approach to treatment of hyperlipidemia includes diet, exercise, and weight loss. Smoking should be proscribed. When nonpharmacologic intervention fails, "statins" are increasingly being selected as agents of first choice. Recommendations for the busy practitioner include consistently identifying the hyperlipidemic patient, setting target goals for lipid values, addressing modifiable risk factors, and providing appropriate pharmacologic intervention (eg, aspirin, antioxidants, and beta blockers in patients with established disease; angiotensin-converting enzyme inhibitors in patients with systolic dysfunction; estrogen replacement in selected patients) and treatment to attain target goals in lowering cholesterol.

Colocare self-test versus Hemoccult II Sensa for fecal occult blood testing.

OBJECTIVES: To compare the efficacy of ColoCARE Self-Test pads against Hemooccult II SENSA, a traditional guaiac-based card test, in the screening for colorectal neoplasia. METHODS: Prospective crossover analysis of 102 high-risk patients for screening of colorectal neoplasia with fecal occult blood testing, using ColoCARE Self-Test pads and Hemoccult II SENSA cards. RESULTS: Sixty-eight of the 102 patients (67%) had colorectal lesions diagnosed at colonoscopy. Of this group, 55 patients (81%) had either a polyp or cancer diagnosed at colonoscopy, with 13 of these 55 patients having polyps > or = 1 cm. ColoCARE detected 21% of all lesions, compared with 72% for Hemoccult II SENSA. ColoCARE detected only 16% of cases involving either a cancer or a polyp, and 24% of cases involving either a cancer or polyp > or = 1 cm in size. This compares with 75% and 95%, respectively, for Hemoccult II SENSA. Significantly more patients preferred ColoCARE (84%) to Hemoccult II SENSA (5%) (p < 0.00001), and patients found it easier to use ColoCARE (p < 0.01). However, 33% of patients did not feel comfortable interpreting the ColoCARE results, and 29% found it difficult to interpret the color change. CONCLUSION: These results indicate that patients may prefer the simplicity and convenience of ColoCARE; however, the test is not sensitive for the detection of colorectal neoplasia. Furthermore, patients do not feel comfortable interpreting ColoCARE results and prefer to have fecal occult blood testing interpreted by medical personnel.

Evaluation of involuntary weight loss. Where do you start?

When a patient presents with involuntary weight loss, the etiologic considerations can be overwhelming. To plan a cost-effective workup, physicians need to be aware of the most common causes of weight loss and the tests that yield the most pertinent data. Drs Wise and Craig review the clinical studies on unintentional weight loss and suggest an initial approach to management.

Munchausen's disorder: a case of a factitious neurological emergency.

Few signs are more ominous than the dilated pupil which is unreactive to light. The deliberate use of this fact and the simulation of other neurologic signs to enhance the aura of a serious illness will often expose a patient to hazardous procedures. A patient with Munchausen's Disorder who made unsuccessful attempts to simulate a neurological emergency is presented. A thorough knowledge of the pathophysiology of neurologic disease will enable the physician to detect the possibility of malingering when confronted with this problem. A strong cholinergic solution will produce pupillary constriction in normals and neurologic disorders but often will not alter the pupil in cases of pharmacologic pupillary paralysis.

Differentiation of early subarachnoid hemorrhage from traumatic lumbar puncture.

The problem of early differentiation of "traumatic tap" from subarachnoid hemorrhage (SAH) was studied in the rabbit by determining the changes in percentage of hemolysis and in lactate concentrations in CSF within the first twenty-four hours following induced SAH. The 0.3 to 7% hemolysis which occurred was relatively independent both of the time following SAH and of the number of red blood cells (rbc) in the cerebrospinal fluid (CSF). There was, on the other hand, a significant and time-dependent increase in CSF lactate concentration early after SAH, suggesting the potential clinical value of the detection of increased lactate with a relatively normal lactate/pyruvate ratio in hemorrhagic CSF. Until this can be evaluated in human subjects, however, determination of the rbc counts or total hemoglobin concentrations in serially collected samples of CSF remains the best clinical method.

Mitomycin C in large infrequent doses in breast cancer.

Seventy-one women with far-advanced breast cancer resistant to standard chemotherapeutic agents were administered mitomycin C using an intermittent high dose schedule. One group consisted of 54 patients with measurable metastatic tumor; a second group consisted of 18 patients with nonmeasurable osseous metastases. Objective response rate in group 1 was 26% for an average duration of 2 1/2 months. Subjective response rate in group 2 was 44% for an average duration of 3 months. Response and toxicity data were similar to those of studies employing the less convenient protracted low-dose schedule. Prior treatment with other alkylating agents did not adversely affect response. Further investigation into the role of mitomycin in combination chemotherapy programs is recommended.