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Biomedical subjects

W Hart

Publications and source records attributed to W Hart.

At least 19 recordsLinked to original sources
PubMed2006

[Clinical reasoning and decision-making in practice. A man with inexplicable joint pain and subsequent poor clinical condition].

A 52-year-old man presented with polyarthritis and was negative for rheumatoid factor, anti-CCP and ANA. He was treated with low-dose methotrexate, the drug of first choice in rheumatoid arthritis. The arthritis disappeared, but the patient developed fever, progressive dyspnoea, appetite loss and weight loss. Upon hospital admission his medication was stopped and community-acquired pneumonia was diagnosed. The fever persisted despite antibiotic treatment. The tentative diagnosis of rheumatoid arthritis was changed to systemic lupus erythematosus, based on the change in clinical condition that could not be explained by polyarthritis and seroconversion to ANA- and anti-dsDNA-positive. The patient was treated with high-dose steroids and azathioprine and remained in remission for more than 1 year after treatment. The ANA test remained strongly positive, whereas anti-dsDNA was no longer detectable. This case stresses the limited value of classification criteria for the diagnosis of rheumatoid arthritis. To differentiate between rheumatoid arthritis and systemic lupus erythematosus, tests for autoantibodies against citrullinated peptides can be used. To differentiate between systemic lupus erythematosus and infection, tests for anti-dsDNA antibodies, antinuclear antibodies, C-reactive protein and complement can be used.

Arthritis, Rheumatoid↗
PubMed2006

[Clinical reasoning and decision-making in practice. A young boy with fever, pancytopenia and an enlarged spleen].

A 5-year-old boy presented with fever and fatigue after a holiday in northern Italy. On physical examination a marked splenomegaly was found. Laboratory investigations showed a pancytopenia as well as several markers suggesting an autoimmune disease. The splenomegaly and pancytopenia continued to progress despite treatment with prednisolone and intravenous immunoglobulins. One and a half years after presentation, the spleen had grown to such an extent that it was causing mechanical problems. Splenectomy was performed for diagnostic and therapeutic purposes. Histological investigation of the spleen showed amastigotes of Leishmania. PCR confirmed the diagnosis visceral leishmaniasis. Leishmaniasis is too often considered to be a tropical disease only. In recent years it has frequently been seen in southern European countries around the Mediterranean Sea.

Child, Preschool↗
PubMed2006

Ammonia and nitrous oxide emissions from two acidic soils of Nova Scotia fertilised with liquid hog manure mixed with or without dicyandiamide.

Gaseous nitrogen (N) loss from field-applied manure in the form of ammonia (NH(3)) and nitrous oxide (N(2)O) has negative agronomic, environmental and health implications. This study was undertaken to evaluate the combined effect of soil type and dicyandiamide (DCD) on NH(3) and N(2)O emissions following application of liquid hog manure. Soil samples (100g) were placed in 500 mL screw-top Mason-jars and de-ionised water was added to bring the soil samples to 50%, 70% and 90% water-filled pore space (WFPS). Slurry and slurry+DCD treatments were applied at a rate of 116000 l ha(-1). The jars were then sealed and incubated at 21 degrees C for 21 d. Ammonia volatilisation was quantified using boric acid traps while N(2)O gas concentrations were analysed using gas chromatography. Results showed that DCD had no effect (p>0.05) on either NH(3) or N(2)O emissions. However, soil type had a significant effect (p<0.05) on both gases. Overall, the Pugwash soil produced 3 and 2.5 times more NH(3) and N(2)O, respectively, than the Acadia soil. N(2)O emissions from both soils increased with an increase in %WFPS, indicating that during the spring and fall in Atlantic Canada, when soils are generally wet, a significant amount of N(2)O may be emitted from these soils. The relationship between cumulative N(2)O and %WFPS was best described by an exponential function R(2)=0.83 and p<0.05 (both soils). Therefore, soil type should be taken into consideration when formulating N(2)O emission factors. The addition of DCD together with slurry may not be a viable strategy to mitigate N(2)O emissions from acidic soils. To reduce emissions of both gases, livestock slurry should not be applied on wet soils.

Acids↗
PubMed2006

[Clinical reasoning and decision-making in practice. A patient with loss of vision and painful legs].

A 69-year-old man was admitted to the Department of Ophthalmology with bilateral loss of vision. For a few months he had also had shooting pains in both legs and instability of gait. Neurological examination showed loss of vision bilaterally and minor sensory disturbances of the legs with diminished tendon reflexes. As extensive further examination showed no specific abnormalities, the tentative diagnosis 'arteriitis temporalis' was made. Despite treatment with corticosteroids his condition deteriorated. Only after a repeat medical history had been taken did it become clear that in the past he had had homosexual contact with a number of partners. This increased the likelihood of a sexually transmitted disease in the differential diagnosis. In the meantime the results from serological tests became known: there were strongly elevated titres for syphilis in both serum and cerebral spinal fluid. Eventually the patient was diagnosed with neurosyphilis with ocular involvement and tabes dorsalis. He recovered almost completely in a few months after treatment with doxycycline.

Aged↗
PubMed2006

[Clinical reasoning and decision making in practice. A 39-year-old woman with somnolence, hypertension and haemolysis].

A 39-year-old woman was admitted with somnolence, severe hypertension and thrombotic microangiopathy. Both malignant hypertension and thrombotic thrombocytopenic purpura (TTP) were considered. Immediate therapy was instituted to treat both diseases because of severe clinical deterioration. Eventually, TTP was considered less likely due to the presence of grade IV hypertensive retinopathy (papilloedema and soft exudates) and a normal Von Willebrand factor-cleaving protease level. Differentiating TTP from malignant hypertension can be difficult as both diseases have similar clinical, laboratory and radiological features. In both diseases, hypertension, thrombotic microangiopathy and encephalopathy with white-matter lesions in the posterior regions of the brain may be apparent. Funduscopic abnormalities consistent with grade III and IV hypertensive retinopathy are rare in TTP, as are normal levels ofVon Willebrand factor-cleaving protease. Therefore, the diagnosis TTP was considered less likely and plasmapheresis was stopped. Hereafter, the laboratory values pointing towards haemolysis remained normal with adequate blood pressure control supporting the rejection of TTP as the cause of the symptoms.

Adult↗
PubMed2005

[Clinical reasoning and decision-making in practice. A patient with oliguria following prostatectomy].

A 70-year-old man with clinically localised prostate carcinoma underwent extraperitoneal endoscopic radical prostatectomy. His medical history revealed hypertension, renal colic, hypogonadotropic hypogonadism and recurrent deep venous thrombosis in the legs. The operation was uneventful with 500 ml blood loss and no periods ofhypotension. The patient developed oliguria within 12 h after surgery. A hypovolemic state was initially suggested to explain the oliguria and increasing amounts of intravenous fluids were administered. The oliguria persisted, however, and the patient did not respond to a diuretic. There was no fluid loss in the drain. Blood pressure, pulse and temperature were normal. Peritonitis and bowel perforation were excluded. Ultrasound examination of the bladder and kidneys revealed an empty bladder and no dilatation of the upper urinary tract, which excluded a post-renal obstruction. The clinical situation deteriorated within hours as the patient developed anuria, bowel distension, metabolic acidosis with progressive renal failure and signs of respiratory distress for which mechanical ventilation was needed. A chest X-ray prior to intubation did not show pneumonia or signs indicating pulmonary embolism. CT of the abdomen was performed to evaluate urinary leakage but revealed no fluid collection or urinoma. Thus pre- and post-renal causes of oliguria were excluded. In view of the systemic symptoms, intra-abdominal pressure was measured using a bladder catheter; it varied between 25 and 35 cm water. Together with the clinical situation, a diagnosis of abdominal compartment syndrome was made and coeliotomy was performed immediately. Within 10 min after decompression of the peritoneal cavity, diuresis started spontaneously. Renal function was restored to preoperative levels in 3 weeks. Abdominal compartment syndrome is a potentially life-threatening cause of anuria. The syndrome should be part of the differential diagnosis for patients with postoperative anuria, including those who underwent extraperitoneal minimally invasive procedures.

Aged↗
PubMed2005

[Clinical reasoning and decision making in practice: a 30-year-old man with unexplained coma].

A 30-year-old man known to have a factor-IX deficiency was presented at the emergency department with unexplained coma. After immediate treatment with factor IX, a CT-scan of the brain revealed no intracerebral haemorrhage. However, blood tests showed severe hyponatraemia, low serum osmolarity and high urine-sodium excretion consistent with the Syndrome of Inappropriate Antiduretic Hormone Secretion (SIADH). Therapy with hypertonic saline was instituted resulting in a gradual rise in the serum-sodium concentration. The cause of the hyponatraemia however remained unclear. After repeat history taking the patient mentioned the use of desmopressin for nocturia. Hyponatraemia as a complication of desmopressin use occurs in 8% of adult patients treated for nocturia. Direct availability of a patient's drug history, by means of an electronic record for instance, could avoid unnecessary tests and delay in diagnosis.

Adult↗
PubMed2005

[Clinical reasoning and decision-marking in practice. A general practitioner with long-standing anaemia].

In order to calibrate his haemoglobin meter, a general practitioner had his own haemoglobin level checked regularly at a nearby laboratory. At 37 years of age, one of these assays revealed 7,0 mmol/l. Because he had no symptoms, he prescribed himself iron-substitution therapy but the haemoglobin concentration did not normalise. At 52 years of age, the patient increasingly suffered from fatigue and exertional dyspnoea and had intermittent abdominal pain, distension and rumbling. Biopsies of the small intestine revealed crypt hypertrophy and intraepithelial lymphocytosis: signs ofcoeliac disease. The symptoms disappeared when the patient started to use a gluten-free diet. The haemoglobin level also normalised. Coeliac disease must be considered in the differential diagnosis of iron-deficiency anaemia.

Adult↗
PubMed2004

[Clinical reasoning and decision making in practice. A 23 year old woman with malaise, anorexia, fever and behavior changes].

A 23-year-old woman presented with a history of some months of malaise, anorexia, fever and behavioural changes. She had been examined by a general physician on repeated occasions before coming to the hospital. After physical examination and laboratory investigations, she was sent home. She returned to the hospital the same day with increased drowsiness and headache. Additional diagnostic procedures were performed. An echocardiography showed vegetations on the mitral valve. A CT scan of the brain showed a left frontotemporal haemorrhage. Infective endocarditis with septic embolisation to the brain, which resulted in a cerebral haemorrhage, was diagnosed. The patient was admitted and intravenous antibiotics were administered. Because of haemodynamic instability, a mitral valve replacement was performed on the fifth day of admission. The patient recovered well postoperatively. Four weeks later, she was found in a comatose condition. She died as a result of a second intracerebral haemorrhage, which was probably caused by a mycotic aneurysm. An important lesson to be learned from this case is that endocarditis should be considered in patients with a long history of anorexia, weight loss, malaise and fever, especially when a heart murmur is present. Secondly, if intracranial haemorrhage has occurred in patients with infective endocarditis, therapeutic options should always be discussed with a neurosurgeon, even in those cases where the probability of a mycotic aneurysm is low.

Adult↗
PubMed2004

[Clinical reasoning and decision-making in practice. A 76 year old woman with gastric carcinoma and cardiac valve disease].

A 76-year-old woman with combined aortic and mitral valve disease presented with anaemia due to a gastric carcinoma. Further staging revealed no evidence for metastatic disease. Approval for surgery for the carcinoma was obtained after a cardiologist and anaesthesiologist were consulted. On the day of surgery, however, the attending anaesthesiologist estimated the operative risk to be unacceptable. The patient reversed her decision and decided not to have the oncological operation, as she felt well at the moment and considered the limited additional survival time not worth the anxiety. The expert opinion of an anaesthesiologist, a cardiologist and an oncologist not primarily involved in this case show that they differ as to the question who is responsible for the decision-making process in patients such as this one. The evidence on estimating operative risk in patients with cardiac valve disease undergoing noncardiac surgery is not unequivocal. Furthermore, there is a shared responsibility when more physicians are involved in the process of decision-making. Agreement on operative risk between physicians is necessary in order to prevent transfer of conflicting information to the patient.

Aged↗
PubMed2004

[Clinical reasoning and decision making in practice. A depressive foreign woman with symptoms of malaise].

A 27-year-old woman was admitted to the hospital with a depression, anaemia and fatigue. She had come from Angola to the Netherlands as a refugee 2 years before this evaluation. As an explanation for her symptoms tropical infectious diseases of parasitic origin were considered, but no clues were found in this direction. The test for trypanosomiasis was considered to be suggestive for an infection in the past (persistent titre 1:200). She was discharged but readmitted 6 months later because of a deterioration of her clinical condition. Magnetic resonance imaging showed bilateral signal abnormalities within the white matter of the brain. On examination no neurological signs or abnormalities were found. Again, no definite diagnosis could be made and the patient was discharged. Because of a further deterioration of her clinical condition she was readmitted a short time later for the third time. On the MRI the white matter lesions had increased. The serum protein electrophoresis was markedly abnormal with an elevated IgM Level. Finally, at a repeated lumbar puncture mobile trypanosomes were found. The diagnosis of 'West African sleeping sickness' was made and the patient was treated with eflornithine. She recovered completely during the next 18 months.

Adult↗
PubMed2003

[Clinical reasoning and decision making in practice. A man with pneumonia and ill smelling watery sputum: the truth revealed after 80 years].

A 24-year-old man was admitted to hospital with pneumonia. On admission he was seen to have an asymmetrical build. During treatment of the lung infiltrate his clinical condition deteriorated. On the third day he coughed up great quantities of fluid which had a urine-like smell. The concentration of creatinine in this fluid was the same as in urine. On X-ray of the thorax, a massive accumulation of pleural fluid was seen. Shortly after aspiration of 1000 ml of pleural fluid the patient died. At autopsy, an ectopic kidney was found in the left thoracic cavity. The pneumonia had caused an abscess that had broken into the pelvis of this ectopic kidney causing the loss of urine into the pleural cavity (urothorax) and 'uroptysis'. On the basis of anatomical and embryological aspects it is debatable if this case was genuine. It is in fact a duplication of a case report published in this journal in 1923 the reliability of which was never clarified. Biographical information from Professor A. Querido (1901-1983) which has since become available indicates that the case was faked by mischievous medical students preparing for their examinations. They had never imagined that the editors might actually accept it for publication. The case report of 1923 has now been retracted.

Adult↗
PubMed2003

[Clinical reasoning and decision making in practice. A man with unilateral attacks of muscular rigidity following neck surgery for a malignant tumor].

A 54-year-old man with a history of generalised tonic clonic seizures presented with complaints of daily unilateral stiffening of the limbs, preceded by paraesthesia. Two years before he had been treated with surgery and radiotherapy for a laryngo-pharyngeal carcinoma. Therefore, epilepsy due to intracerebral metastasis was suggested. However, neither CT nor MRI of the brain (with intravenous contrast) showed any abnormalities and the EEG showed no epileptiform discharges. Laboratory tests revealed elevated levels of thyroid-stimulating hormone in the blood, hypocalcaemia, hyperphosphataemia and hypomagnesaemia. In combination with the medical history, tetany was found to be the correct diagnosis. In this patient, tetany was caused by hypoparathyroidism secondary to surgery and radiotherapy in the neck region. He was treated with levothyroxine, magnesium, calcium, and vitamin D and recovered in a few weeks' time. Hypothyroidism and hypoparathyroidism are common complications after treatment (surgery, radiotherapy and/or chemotherapy) for laryngo-pharyngeal carcinoma and other malignancies in the neck region.

Calcium↗
PubMed2003

[Clinical reasoning and decision making in practice. A 41-year old with periodic fever of unknown origin].

A 41-year-old man presented with unexplained bleeding from the right tonsil. He subsequently developed periodic fever, cervical lymphadenopathy and hepatosplenomegaly. Despite extensive bacteriological, serological and radiographic investigations for infectious disease, rheumatic disease and malignancy no diagnosis was made. Although the fever pattern was very suggestive of Pel-Ebstein fever--commonly associated with lymphoproliferative disease--multiple biopsies of lymph nodes, bone marrow, tonsils and liver all proved negative. Empirical glucocorticoid therapy gave some temporary improvement lasting for a month. Splenectomy or splenic biopsy was not carried out because of the risk of excessive bleeding. Eventually the patient died of multi-organ failure and sepsis. At autopsy, a T-cell lymphoma with an unusual phenotype and focal involvement of bone marrow, liver and spleen was found. Clinicians are sometimes faced with the dilemma of whether to perform multiple, invasive and possibly harmful diagnostic tests or to start empirical therapy. Empirical therapy may only be started if the diagnosis has been made on strong clinical grounds and, if this is not the case, only after further diagnostic tests. The question of whether a potentially harmful diagnostic test is justified depends on the clinical course, the sensitivity and specificity of the test and the therapeutic possibilities.

Adult↗
PubMed2003

[Clinical reasoning and decision-making in practice. A young woman with fever, shortness of breath, and reduced consciousness].

A 23-year-old woman with mild psychomotor retardation presented with fever, coughing, reduced consciousness and a stiff neck. A chest X-ray revealed an infiltrate in the left lower lobe; the cerebrospinal fluid was cloudy with a mild pleocytosis. Ceftriaxone was prescribed and the fever subsided. On the second day of admission she had a seizure, and a paraparesis emerged. Despite changes in the antibiotic regimen, her clinical condition hardly improved. On the fifth day, antibodies against Mycoplasma pneumoniae were found to be strongly positive and the diagnosis was M. pneumoniae infection. This accounted for the pneumonia together with meningoencephalitis and a transverse myelitis. The antibiotics were switched to doxycycline and the clinical condition improved dramatically. Six weeks after discharge, the patient had made a complete recovery. In patients suffering from meningitis with an atypical presentation, uncommon causes of infection should be considered. Together with a pneumonia, M. pneumoniae, Chlamydia pneumoniae, Legionella pneumophila and Listeria monocytogenes should be high on the list of potential causes for bacterial meningitis.

Adult↗
PubMed2002

[Nutrition and health].

In this issue the journal publishes the first of a series of articles on nutrition and health. Dutch investigators have contributed to food research since the work of Eijkman and co-workers on vitamins at the end of the nineteenth century. During the last forty years, food research has moved towards investigating the role of nutrients in the prevention of diseases with a long latency and in specific population groups, e.g. the elderly and people with hypertension or obesity. More recent research has focused on enriched food products and biotechnologically manufactured nutritional elements. The series will discuss subjects such as dietary reference intakes, dietary infections, dietary requirements of the elderly and patients in hospitals and rehabilitation institutions, and the beneficial and detrimental effects of alcohol consumption. This will enable the clinician to provide answers to patients' questions regarding their diet and to recommend a healthy diet.

Diet↗
PubMed2002

[Clinical reasoning and decision making in practice. Fever, purpura and hemiparesis in a 29-year old female].

A 29-year-old female was admitted with fever, purpura and hemiparesis. She was treated for meningococcal sepsis after a Gram stain of a purpuric lesion showed Gram-negative diplococci. CT scan of the brain revealed multiple haemorrhagic lesions with obliteration of the sulci and basal cisterns. In the course of the disease she developed an acute myocardial infarction. Besides wall motion abnormalities, echocardiography revealed a bicuspid aortic valve with a vegetation on one of its cusps. Despite these findings, both the doctors who were involved in the treatment of this patient and the consulted physician in this article failed to reject the diagnosis 'meningococcal sepsis' and to replace it with a more likely diagnosis, namely Staphylococcus aureus endocarditis. The patient died one day after admission due to transtentorial herniation. Although purpuric lesions are common in meningococcal sepsis, they are not specific for this disease. The false-positive result of the Gram stain resulted in a process known as 'premature closure': the diagnosis of meningococcal sepsis was accepted before it was fully verified. In this case, the consequence was that other diagnostic tests and symptoms were misinterpreted with the result that inappropriate antibiotic therapy was instituted.

Adult↗