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AFP Journal Review. July 1, 2007 Dr Anjum Qazi. Articles. Nausea and Vomitting Cysticercosis Dupuytren’s disease. Strength of Recommendation Grades. A – Consistent, good quality patient oriented evidence B – Inconsistent or limited quality patient oriented evidence
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AFP Journal Review July 1, 2007 Dr Anjum Qazi
Articles • Nausea and Vomitting • Cysticercosis • Dupuytren’s disease
Strength of Recommendation Grades • A – Consistent, good quality patient oriented evidence • B – Inconsistent or limited quality patient oriented evidence • C – Consensus, disease oriented evidence, usual practice, expert opinion, or case series for studies of diagnosis, treatment, prevention, or screening
Definition / Introduction • Unpleasant sensation of impending vomitting is nausea • Retching is a strong involuntary effort to vomit without bringing up emesis • Vomitting is an involuntary forceful expulsion of stomach contents • Nausea and vomiting significantly affect quality of life. In a study of 17 gastrointestinal conditions in the United States, it was estimated that the cost of acute gastrointestinal infections exceeds $3.4 billion
Emetic center is located in the reticular formation of the medulla oblongata and is rich in H1, M (Muscarinic/cholinergic) and serotonin receptors This center can be stimulated by • Stomach or biliary duct distension via vagal afferents • Vestibular dysfunction via H1/M receptors • Metabolic derangements, toxins and some medications (cardiac glycosides, chemotherapy, opiates) via the CTZ rich in 5HT3 and D2 receptors • Inflamation or ischemia of the heart, pericardium, liver, pancreas/GB or Peritonium
Question 1 Which one of the following antiemetic drugs is the best tolerated? A. Metoclopramide (Reglan). B. Ondansetron (Zofran). C. Prochlorperazine. D. Trimethobenzamide (Tigan).
Answer B. Ondansetron (Zofran).
Question 2 Which one of the following studies is recommended initially for detecting suspected small bowel obstruction? A. Upper endoscopy. B. Enteroclysis. C. Small bowel follow-through. D. Supine and upright abdominal radiography.
Answer D. Supine and upright abdominal radiography.
Cysticercosis (Tapeworm infection) • Common parasitic disease worldwide • Endemic in Mexico, Central and South America, parts of Africa, Asia and India • Neurocysticerosis is one of the leading causes of adult onset seizures worldwide.
Its clinical effects vary depending on site of larval lodging, larval burden, and host reaction. • These effects include seizures, headaches, focal neurologic symptoms, visual disturbances, and localized skeletal muscle nodules and pain. • Brain and eye cyst cause the most morbidity with brain being the most (60-90%)and eye being the least common (1-3%) • Cysticercosis should be considered in any patient from an endemic area presenting with these symptoms. • Treatment varies with the clinical presentation
Question • Recent immigrant from South America presents for a new patient visit. His CT is as follows. Which of the following clinical presentations may be observed with the CT finding • Seizures • Visual disturbances • Headaches • Localized skeletal muscle nodules and pain
Answer • All of the above
Dupuytren’s disease • Dupuytren's disease is a progressive condition that causes the fibrous tissue of the palmar fascia to shorten and thicken. • Common in men older than 40 years; in persons of Northern European descent; and in persons who smoke, use alcohol, or have diabetes. • Patients present with a small, pitted nodule (or multiple nodules) on the palm, which slowly progresses to contracture of the fingers.
The Hueston tabletop test can help with the diagnosis. If a patient is unable to lay his or her palm flat on a tabletop, the test is positive • In patients younger than 50 years, Dupuytren's disease tends to progress faster than in older patients. The disease usually progresses in severity, although approximately 10 percent of cases regress without treatment.
Disease progression is classified using a grading system Grade 1 presents as a thickened nodule and a band in the palmar aponeurosis that may progress to skin tethering, puckering, or pitting. Grade 2 presents as a peritendinous band that limits extension of the affected finger. Grade 3 presents as flexion contracture.
Question • Which one of the following in a patient with Dupuytren's disease requires referral to a hand surgeon? A. Positive Hueston tabletop test. B. 15-degree metacarpophalangeal joint contracture. C. Skin pitting. D. Nodule size greater than 5 mm.
Answer • A. Positive Hueston tabletop test.
Question • Which one of the following has been shown to be strongly associated with Dupuytren's disease? A. Diabetes. B. Trauma. C. Epilepsy. D. Anticonvulsant medication use.
Answer A. Diabetes.
