The basic clinical diagnostic framework synergized

OBJECTIVE

To develop a diagnostic framework that would help defining clinical problems by the expanded understanding with traditional Chinese medicine (C Med) and western medicine (W Med).

METHODS

The basic attributes of diagnosis and the use of diagnostic techniques of W Med and C Med are reviewed. Some of the various diagnostic labels and their meanings are also preliminarily reviewed. A consolidatory approach is made to synergize the usefulness of the two disciplines based on the principles of the two schools.

RESULTS

A synergized basic diagnostic framework is developed. The disease (the disease diagnosis, [symbol: see text]), the state of the inner core (the core diagnosis, [symbol: see text]) should be defined. The term "systemic clues" is used to describe the symptom complex and conglomerate evidence describing the transient or sustained reaction of the inner core to environment. This is an analytical summary of its pathophysiological changes in reaction to the environmental insults.

CONCLUSIONS

The application and use of the framework are discussed and propositions are made. The synergized diagnostic platform represents a starting effort to form a unified basis to exchange clinical diagnosis between W Med and C Med. Such framework may facilitate looking for new treatment modalities and results can be compared across different centres.

Identification of the proteolytic enzyme which cleaves human p75 TNF receptor in vitro

The extracellular domains of the human 55 and 75 kD TNF receptors (p55 and p75 TNF-R) are proteolytically cleaved to produce 30 and 40 kD soluble fragments, respectively. In this study, the enzymatic activity involved in the cleavage of human p75 TNF-R, named TNF-R releasing enzyme (TRRE), was identified in the culture supernatant of PMA-stimulated THP-1 cells using an activity assay system established by our group. When THP-1 cells were stimulated with PMA, TRRE was released rapidly into the supernatant, reaching maximal activity within 3 hours. The release of TRRE into the culture supernatant depended on the concentration of PMA and FCS. TRRE activity was partially inhibited by chelating agents, suggesting that TRRE may be a metallo-protease-like enzyme. This is the first successful attempt to establish a stable TRRE source with a reliable assay system.

Hepatitis B virus associated membranous glomerulonephritis in children--experience in Hong Kong

A retrospective review was undertaken on all renal biopsies performed in Chinese children under 13 years of age in Queen Mary Hospital, Hong Kong from 1980 to 1990. Of 172 renal biopsies, 18 cases were diagnosed to be membranous glomerulonephritis. All were associated with hepatitis B virus infection. Fourteen patients presented with, and 3 others developed later nephrotic syndrome. Hematuria was a common feature (83%). Complement C3 was low in 5 cases and they became normal later. At last observation, 10 patients (59%) remitted, usually within 3 years. One had persistent proteinuria and 5 had nephrotic syndrome. One patient developed end-stage renal failure 12 years after onset of illness. All three female patients completely remitted. Of the 15 boys, 50% remitted whether they received steroid treatment or not. Two patients received interferon alpha-2a therapy. One achieved remission but HBsAg and HBeAg persisted. The other had transient seroconversion and clinical improvement but nephrotic syndrome returned after stopping treatment.

Interferon treatment for hepatitis B-associated membranous glomerulonephritis in two Chinese children

Two Chinese boys, aged 3.5 and 5 years, developed nephrotic syndrome and were chronic carriers of hepatitis B virus surface antigen (HBsAg) and hepatitis B virus e antigen (HBeAg). Renal biopsy showed membranous glomerulonephritis and liver biopsy showed chronic persistent hepatitis. They were given interferon-alpha-2a at a dose of 5 MU/m2 on alternate days for 12 and 16 weeks after 2 years of persistent nephrotic syndrome. Patient 1 showed complete remission and resolution of hepatosplenomegaly, but his serum remained positive for HBsAg, HBeAg and hepatitis B virus DNA. Patient 2 showed only a transient clinical response and seroconversion from HBeAg to anti-HBe status. Although not always successful, interferon treatment should be considered in severe persistent nephrotic states, since there is at present no satisfactory treatment for this form of glomerulonephropathy.

Hyperinsulinism in infancy

Five infants with persistent hypoglycaemia due to hyperinsulinism were reported. Provocative tests for insulin release were unhelpful. Diazoxide was useful in the treatment of three patients but many side-effects were observed. These included petechial rash, hypertrichosis, acute renal failure, fluid retention and cardiac failure. Two patients underwent spontaneous remission. Three patients had nesidioblastosis, two of whom were subjected to 95% pancreatectomy. Postoperatively, recurrence of hypoglycaemia was due to hyperinsulinism in one patient and to presumed glucagon deficiency in the other. Phenytoin effectively corrected the hypoglycaemia in the patient who had postoperative hyperinsulinism. It is recommended that medical therapy with diazoxide (10-15 mg/kg per day) together with a diuretic be commenced once hyperinsulinism is diagnosed. Subtotal pancreatectomy should be performed early in these patients if hypoglycaemia cannot be controlled with medical therapy or if side-effects of treatment are documented.

Encephalopathy associated with steroid treated nephrotic syndrome

Four children with nephrotic syndrome convulsed and became comatose during steroid therapy. The attacks were associated with hypokalemia and occurred around the time of diuresis. The blood pressure readings were constant in two patients and transiently increased in the other two during the convulsions. All four patients had poorly controlled proteinuria more than one month before the attacks. Various factors including hypertension with secondary cerebral vasoconstriction, hypercoagulable state leading to cerebral microthrombosis and steroid therapy may have contributed to the problem. It is suggested that monitoring patients with electroencephalogram during steroid therapy in long-standing nephrotic states before diuresis may be useful. Hypokalemia should be taken as an ominous sign.

Problems and proposals for interview data in epidemiological research

We assessed the reliability of epidemiological data obtained by interview of 120 patients in a case-control study. The collected data, which were obtained by interview on two separate occasions, included such clinical and pharmaceutical features as history of lactation, hysterectomy, diabetes, type of menopause, and whether a woman had ever used exogenous oestrogens. Although we found generally high rates of agreement between interviews, errors in collecting and classifying data did occur, and were especially common for complicated clinical events, such as whether an oophorectomy accompanied the surgical removal of the uterus. Patients were also likely to disagree with previous responses when asked to recall a drug exposure occurring many years before. We identified seven sources of this variability, five in collecting the data, and two in coding. As a result of these findings, strategies are proposed for improving the quality of interview data obtained in epidemiological research.

Closed dorsal dislocation of the metatarsophalangeal joint of the great toe. A surgical approach and case report

A rare injury consisting of an irreducible, closed complex dorsal dislocation of the metatarsophalangeal joint of the great toe was encountered in a 21-year-old man. A midline longitudinal dorsal incision over the metatarsophalangeal joint allowed easy and rapid approach to the joint, good visualization, and adequate access for reduction. The plantar neurovascular bundles are not at risk from the exposure, and scarring in the weight-bearing area after operation is avoided.

Assessing the reliability of epidemiologic data obtained from medical records

We assessed the reliability of epidemiologic data extracted by three data technicians from the medical records of 102 patients in a case-control study. The collected data, which were extracted on two separate occasions, included such clinical and pharmaceutical features as history of lactation, hysterectomy, diabetes, and hypertension, type of menopause, and whether a women had ever used exogenous estrogens. Although we found high rates of intra- and interextractor agreement, some errors in excerpting and classifying data did occur, and were especially common in making distinctions between uncertain data (due to ambiguous or incomplete descriptions) and negative responses (indicating that a feature was truly absent). We were able to discern six distinctive sources of this variability, four in excerpting the data from the hospital record, and two in coding the excerpted data. As a result of these findings, strategies are proposed for improving the basic quality of data used in epidemiologic research.

The use of skin temperature determinations in lower extremity amputation level selection

Skin temperatures were recorded preoperatively with a surface temperature probe in 30 limbs of 26 patients undergoing amputations for peripheral vascular disease. A significant correlation was established between the temperature readings and stump survival at the selected levels. All amputation levels with temperature readings above 32° C healed, and all those with readings below 30.5° C failed to heal. If the difference between skin temperature and room temperature was less than 5° C the amputation generally failed.