Mistaken hilar mass.
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Biomedical subjects
Publications and source records attributed to F W Wright.
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A patient-powered treadmill was compared with the covered corridor walking test as assessments of exercise capacity in heart failure patients, and used to investigate their sensitivity in discriminating between the effects of xamoterol and placebo. The two methods were comparable, and sufficiently sensitive to demonstrate improvements in exercise capacity on xamoterol. The treadmill was more sensitive and could be useful as an assessment of treatment of heart failure in family practice.
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A prospective, randomized, double-blind between-patient study was carried out to compare the efficacy and tolerance of atenolol with nifedipine and atenolol with diuretic. Ninety-eight hypertensive patients inadequately controlled after 1-month's treatment with 100 mg atenolol alone once daily received, in addition, either 20 mg nifedipine twice daily or 5 mg amiloride plus 50 mg hydrochlorothiazide once daily for a further 8 weeks. The results of blood pressure measurements in the lying and standing positions showed that the mean reduction in standing blood pressure from atenolol baseline was 28/12 mmHg for atenolol/diuretic and 18/13 mmHg for atenolol/nifedipine. The only significant difference between treatments in blood pressure control was in lying systolic blood pressure favouring atenolol/diuretic and a trend in favour of this combination for standing systolic blood pressure. Both regimens were reasonably well tolerated, although 19 patients withdrew during the course of the trial because of side-effects (2 on atenolol alone, 10 on atenolol/diuretic and 7 on atenolol/nifedipine).
To identify patients at risk from renal bone disease we compared the demographic characteristics of 243 patients with end stage renal failure grouped according to the presence (97 (40%] or absence of severe renal bone disease as judged by histological criteria. Youth, female sex, tubulointerstitial types of nephropathy, and a long duration of uraemia were all identified as significant independent risk factors for the development of bone disease. The relative risks from being female and having tubulointerstitial renal disease were separately identifiable when the estimated observation of renal failure was short (less than four years). The identification of patients at high risk from bone disease may clarify the pathogenesis and treatment strategies of renal osteodystrophy.
Severe radiation burns to the skin and deeper tissues resulting from diagnostic radiology have fortunately been very rare in the United Kingdom. It is hoped they will now be only of historical or academic interest. For this reason a very severe radiation burn to the right hand of a young woman, caused by prolonged fluoroscopy in removing a metalic foreign body, is described. This resulted in a severe sloughing of the skin of the dorsum of the hand that had to be grafted. Subsequently progressive bone necrosis occurred and the hand has never been fully useful since the accident. It is noteworthy that a surgical assistant also sustained radiation burns to the fingers.
Hilar and mediastinal node enlargement may be a manifestation of the spread of renal tumours. However, the author believes the spread to these nodes may occur either via the upper para-aortic nodes or directly by way of lymphatic vessels from the kidneys by-passing the upper abdominal nodes. It seems that in some cases the hilar node may even be acting as a regional lymph node for the kidney. Thus an enlarged hilar node and especially a lower right hilar node may be the presenting feature of a renal tumour.
Gas within clefts of fissures in gallstones is not a very common finding, but when it occurs is, characteristic and indicates the presence of one or more calculi. It closely resembles the appearance of a 'Jack Stone' but has previously been termed the 'Mercedes Benz' sign. Only a few cases have previously been recognised in the U.K. Most reported cases have been associated with biliary colic or cholecystitis. Various theories have been put forward to explain the presence of gas, but the author believes that the gas is released from solution by negative pressure within cholesterol stones undergoing internal fissuring due to their crystalline structure, i.e. the gas is released from solution from the small amount of fluid trapped in the calculus, in the same way that gas may be 'pulled' out of solution in a joint, a degenerate intervertebral disc or the fibro-cartilage of the symphysis pubis.
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The recognition of traumatic splenic rupture in an 11-year-old severely affected haemophilic boy was delayed for over five weeks. Splenectomy was carried out successfully after the demonstration of splenic rupture by an isotope spleen scan. Splenic rupture is difficult to differentiate from more simple causes of retroperitoneal haematomata in haemophiliacs when there is no massive acute peritoneal bleeding, but it may be identified with isotopic spleen scans so long as the possibility of rupture is borne in mind.
Tumours of the lung, primary or secondary, may occasionally be complicated by a pneumothorax, and on rare occasions this may be the presenting feature. Metastatic tumours associated with pneumothorax arise usually from bone or soft tissue sarcomas and hence are more common in the young.
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In the absence of abdominal operative procedures, symptomless spontaneous pneumoperitoneum is uncommon. The case is described of a patient with jejunal diverticulosis who developed spontaneous pneumoperitoneum on three occasions and brief details are given of six other cases of jejunal diverticulosis with pneumoperitoneum from the literature. Other causes of symptomless pneumoperitoneum include pneumatosis intestinalis, perforation in tabes dorsalis or coma, stercoral ulceration, physiological pneumoperitoneum in women due to exercise in the knee-elbow position, and vaginal douches with a bulb syringe or effervescent fluid.
In the past 9 years we have encountered 3 renal space-occupying lesions, which were "avascular" at arteriography but which appeared to be tumours, as shown by renal puncture of "antegrade" pyelography, All had an irregular inner border demonstrated. The investigation and radiological diagnosis of such masses is discussed thad compared with that of renalcysts.