The correct answer is 1. The symptoms and signs described are the biological findings associated with anorexia nervosa. The ECG disturbances are derived from electrolyte disturbances.

[HIDDEN] The symptoms and signs described are the biological findings associated with anorexia nervosa. The ECG disturbances are derived from electrolyte disturbances.

A 13-year-old girl consults us for weight loss, asthenia, secondary amenorrhea and constipation. Examination revealed a temperature of 35ºC, weight below the 3rd percentile, bradycardia and orthostatic hypotension. Laboratory tests showed anemia with mild leukopenia, cholesterol of 230 mg/dL and on the electrocardiogram a flattened T wave with ST-segment elevation and prolonged QTc. What process would you suspect and what would you do next?

Suspect anorexia nervosa and inquire about intake, body image, etc.

Suspect hypothyroidism and request TSH and thyroid hormones.

Suspect cardiomyopathy and request echocardiography.

I would suspect celiac disease and request anti-transglutaminase IgA antibodies.

Suspect panhypopituitarism and request a cranial CT scan.

[Anorexia with sinus bradycardia: a case report].

As anorexia patients always go to the psychiatric clinic, little is concerned about the occurrence of sinus bradycardia in these patients for cardiologists and psychiatrists. The aim of this paper is to discuss the relationship between anorexia and sinus bradycardia, and the feature analysis, differential diagnosis and therapeutic principles of this type of sinus bradycardia. We report a case of sinus bradycardia in an anorexia patient with the clinical manifestations, laboratory exams, auxiliary exams, therapeutic methods, and her prognosis, who was admitted to Peking University Third Hospital recently. The patient was a 19-year-old female, who had the manifestation of anorexia. She lost obvious weight in a short time (about 15 kg in 6 months), and her body mass index was 14.8 kg/m(2). The patient felt apparent palpitation, chest depression and short breath, without dizziness, amaurosis or unconsciousness. Vitals on presentation were notable for hypotension, and bradycardia. The initial exam was significant for emaciation, but without lethargy or lower extremity edema. The electrocardiogram showed sinus bradycardia with her heart rate being 32 beats per minute. The laboratory work -up revealed her normal blood routine, electrolytes and liver function. But in her thyroid function test, the free thyroid (FT) hormones 3 was 0.91 ng/L (2.3-4.2 ng/L),and FT4 was 8.2 ng/L (8.9-18.0 ng/L), which were all lower; yet the thyroid stimulating hormone (TSH) was normal 1.48 IU/mL (0.55-4.78 IU/mL). Ultrasound revealed her normal thyroid. Anorexia is an eating disorder characterized by extremely low body weight, fear of gaining weight or distorted perception of body image, and amenorrhea. Anorexia patients who lose weight apparently in short time enhance the excitability of the parasympathetic nerve, and inhibit the sympathetic nerve which lead to the appearance of sinus bradycardia, and functional abnormalities of multiple systems such as hypothyroidism. But this kind of sinus bradycardia and hypothyroidism have good prognosis. And asymptomatic sinus bradycardia with reversible causes, because of the great prognosis, they do not need special treatment. Multiple medical and psychiatric disciplines were consulted, and then, family care, nutritional support and psychiatric therapy were given, and she did not need thyroid hormone replacement therapy. The patient's overall clinical status improved gradually during her hospital stay and her heart rate was recovered to 55 beats per minute.

Case Report.

Thyroid hormone resistance (RTH) is defined as a decrease in response to thyroid hormones in the target tissue. Most patients present with nonspecific findings. In this article, we aimed to represent a 22-year-old female patient who presented with palpitation, fatigue, and heat intolerance. She was thought to have thyroid hormone resistance and her genetic examination revealed NM_001128177.1 (THRβ): c.1034G > A (p.Gly345Asp) pathogenic variation in the THRβ gene. A 22-year-old female patient presented with complaints of fatigue, heat intolerance and palpitations. She was taking Propranolol twice daily at admission. Her family history revealed hypothyroidism in her grandmother. Her physical examination results were as follows: height 160 cm, weight 65 kg, body mass index 25.4kg/m<sup2</sup, body temperature 36.5°C, respiratory rate 18/min, heart rate 86 beats/min, blood pressure 120/80 mmHg. Her palms were sweaty. The heart sounds were normal, and no heart murmur was auscultated. The laboratory results were TSH: 5.31uU/mL, fT3: 6.83 pg/mL, and fT4: 2.43 ng/dL. THRβ gene mutation analysis was requested for our patient whose clinical history and laboratory results were compatible with thyroid hormone resistance. The pathogenic variation NM_001128177.1(THRβ):c.1034G>A (p.Gly345Asp) was detected after analysis. A diagnosis of RTH requires high clinical suspicion and a genetic mutation analysis should be requested in the case of clinical suspicion. In this way, unnecessary anti-thyroid treatment can be prevented.

[Anorexia nervosa in boys--a case report].

In contrast to female adolescents, anorexia nervosa is rarely seen in male adolescents. In consequence, more comprehensive investigations are often carried out in the latter in a search of organic disease. A boy of thirteen-and-a-half years was referred for investigation of anorexia, loss of weight, constipation, loss of concentration and depression. Physical examination revealed bradycardia, low blood pressure, hypothermia and various endocrinological disturbances: reduced somatomedin C, tri-iodine thyronine and subnormal thyroxine levels, and delayed TSH peaking after TRH stimulation. Examination of peripheral blood revealed leukopenia with underlying hyperplastic bone marrow. A CT scan revealed widening of the ventricles of the brain, and echocardiography a mitral valve prolapse. Anorexia nervosa is accompanied by numerous pathological findings which, however, when weight is regained, return to normal without the need for further treatment. Before instituting invasive diagnostic measures in boys or male adolescents, consideration should be given to anorexia nervosa, and a psychiatric consultation sought.

Thyroid and Parathyroid Conditions: Hypothyroidism.

Hypothyroidism is caused by deficient thyroid hormone production secondary to autoimmune disease or insufficient iodine consumption or as a complication of hyperthyroidism management. Signs and symptoms include fatigue, weight gain, dry skin, constipation, and cold intolerance. The U.S. Preventive Services Task Force found insufficient evidence to recommend for or against screening for hypothyroidism, but some organizations support screening in special populations. If hypothyroidism is suspected, initial laboratory evaluation consists of a serum thyrotropin (TSH) measurement with reflex testing of free thyroxine (T<sub4</sub). Thyroid function tests must be interpreted carefully because acute illness, diet, and drugs may alter values. Overt hypothyroidism occurs when a patient has an elevated TSH level and a low free T<sub4</sub level with symptoms of hypothyroidism. Management includes thyroid hormone replacement, ideally levothyroxine. Subclinical hypothyroidism is characterized by an elevated TSH level with a normal T<sub4</sub value. The decision to treat subclinical hypothyroidism should be based on patient characteristics and shared decision-making discussions. Special consideration should be taken in treating patients with high-risk conditions, including heart disease, pregnancy, and myxedema coma, and in patients requiring high-dose levothyroxine. Thyroid hormone should be titrated based on goal TSH values, symptoms, and potential treatment adverse effects.

Referral letters for 2-week wait suspected colorectal cancer do not allow a 'straight-to-test' pathway.

Some clinicians have argued that 2-week wait suspected colorectal cancer patients can go 'straight-to-test' to facilitate time to diagnosis and treatment. The aim of this study was to evaluate whether the currently used referral letters are reliable enough to allow that pathway. General practitioner (GP) letters referring patients under the Two Week-Wait Rule for suspected colorectal cancer were prospectively reviewed over a 6-month period. Three examining consultants were asked to outline the tests they would perform having only read the letter, and then again after a clinical consultation with the patient. The outcome of these tests was tracked. A total of 217 referral letters of patients referred under Two Week Wait Rule for suspected colorectal cancer were studied. Having just read the referral letter, the most frequently requested test was colonoscopy (148), then CT scan (48), barium enema (44), followed by gastroscopy (23) and flexible sigmoidoscopy in 15 patients (some patients would have had more than one test requested). After consultation with the patients, tests requested as guided by the GP letter were changed in 67 patients (31%), where 142 colonoscopies, 61 CT scans, 37 barium enemas, 23 flexible sigmoidoscopies and 19 gastroscopies were organised. The referral indication which had tests changed most often was definite palpable rectal mass (67%), while patients referred with definite palpable right-sided abdominal mass had their tests least often changed (9%). A total of 22 patients were found to have colorectal cancers (10%) and 30 patients were diagnosed with polyps (14%). Out of 142 colonoscopies performed, 19 (13%) showed some pathology beyond the sigmoid colon and of the 23 patients who had flexible sigmoidoscopy initially, only three went on to have colonoscopy subsequently. During the 6-month period of the study, only five breaches of the waiting time targets were recorded (1 to the 31-day target and 4 to the 62-day target). A significant number of patients would have had tests changed after a clinical consultation. However, only a small number required further investigations having had a consultation prior to their initial investigations. We conclude that 2-week wait suspected colorectal cancer patients should be seen in the clinic first and should not proceed 'straight-to-test'.

[The heart of anorexic adolescents].

Anorexia nervosa (AN) is often associated with cardiac changes, such as thinning of the left ventricle (LV), reduction of LV mass, abnormalities of mitral valve function and systolic dysfunction. Some authors have reported QT interval prolongation and sudden death in these patients. We studied 23 adolescent females, aged 14.7 +/- 2 years (mean +/- SD), with AN. Serum electrolytes, proteins and albumin were measured in all patients. Electrocardiogram, Doppler-echocardiogram and chest X-rays were also performed on the same day. Eighteen patients were also examined via indirect calorimetry (difference from basal metabolic rate) and 21 underwent dosage of thyroid hormones. The patients, who were of normal height (159 +/- 7.4 cm), were underweight (36 +/- 4.8 kg) and had a body mass index (BMI) of less than 19 (14.2 +/- 1.3). Serum electrolytes, proteins, albumin and chest X-rays were substantially normal in all patients; 74% of them showed reduction of FT3. The calorimetry was reduced (-27.1 +/- 10.6%) with the exception of one patient. Resting heart rate was 58 +/- 12 bpm. We found normal values for PR, QRS, QT (0.41 +/- 0.03 s1/2) and QTc intervals (0.40 +/- 0.03 s1/2) and QT dispersion (40.9 +/- 14.1 ms). Echocardiography showed a reduction in the dimensions of the interventricular septum (52% of patients), LV free wall (61%), left atrium (31%) and LV mass (61%). Fractional shortening was normal in all but one patient. In 61% of cases, there was mild or moderate pericardial effusion that was clinically silent and inversely related to BMI (r = -0.38, p 0.08, ns), to calorimetry (r = -0.56, p < 0.0055), to FT3 (r = -0.53, p < 0.05) and to sodium concentration (r = -0.43, p 0.04). Teen-agers with AN often show a reduction in LV thickness and mass, as well as clinically silent pericardial effusion that is inversely related to BMI, calorimetry, FT3 and sodium serum concentrations. We did not find any prolongation of QTc interval or of QT dispersion.

Polyglandular Autoimmune Syndrome Type I -- History and Physical

Autoimmune hypothyroidism or Hashimoto hypothyroidism, characterized by the presence of anti-thyroid peroxidase (TPO) antibodies anti-thyroglobulin antibodies may also be present. Clinical features include weight gain, loss of appetite, cold intolerance, and constipation. Diagnosis is by measuring thyroid-stimulating hormone (TSH) and thyroxine (T4) levels.

[Case report: recently diagnosed celiac disease as aggravating factor of osteoporosis in an old woman].

Sixty-three-year-old woman requested medical attention for osteoporosis. Bone densitometry revealed: T(spine (L1-L4))= -3.5 SD [Bone mineral density (BMD): 0.766 g/cm(2)]. T(femoral neck) = -2.4 SD (BMD: 0.716 g/cm(2)). She has been in calcium and vitamin D supplementation for 2 years. She informed a 5-year-history of hypothyroidism in levothyroxine replacement. Alendronate sodium 70 mg/week was initiated with significant increase in BMD in the first year (6.1% equally in spine and femoral neck). After a 5-year follow-up, the patient presented with weight loss, anemia and decrease in BMD (12.6% in spine and 20.9% in femoral neck). Clinical history revealed intermittent diarrhea episodes for 2 years and the hypothesis of celiac disease was suspected. Anti-gliadin and anti-endomysium antibodies were positive: 25.3 U/mL (< 20) e 1/5 U/mL (RV: negative), respectively. Bone biochemical parameters revealed normal levels of calcium and phosphate, increased parathyroid hormone: 283 pg/mL (10-65) and increased levels of bone reabsortion markers, consistent with secondary hyperparathyroidism in response to malabsorptive syndrome. One year after gluten-free diet, patient improved of malabsorptive symptoms and gained BMD (47.3% in spine and 31.6% in femoral neck), confirming the hypothesis of celiac disease as aggravating factor of osteoporosis in this patient.

[Clinical study of 105 cases of isolated weight loss in internal medicine].

We arbitrarily define "isolated weight loss" as the loss of at least 10 p. 100 of body weight over less than one year, without any single cause being disclosed by questioning, physical examination and such paraclinical examinations as blood electrolytes, blood count and differential, routine dipstick urinalysis and X-ray of the chest. Among the 105 patients we studied, the causes of isolated weight loss were: (1) psychic disorders (chiefly depression) in 60 p. 100 of the cases; (2) a variety of organic diseases in 29 p. 100, including gastrointestinal diseases (8 p. 100), cardiovascular and respiratory diseases (6 p. 100), Horton's disease (4 p. 100), Portuguese amyloidosis (1 p. 100), unexplained inflammatory syndrome (1 p. 100), endocrine disease (hyperthyroidism, 4 p. 100) and intoxication with medicines, alcohol or heroin (5 p. 100); (3) no definite cause could be found in 11 p. 100 of the cases. We suggest a diagnostic approach involving a limited number of examinations, viz.: erythrocyte sedimentation rate, measurement of transaminases, gamma GT and alkaline phosphatase enzymes, abdominal ultrasonography and ultra-sensitive TSH assay. We consider it important to switch from useless paraclinical tests to the detection and management of psychic disorders. Weight loss is a frequent motive of consultation, but its diagnostic value is often misunderstood. The purpose of this study was to provide data for the artiological diagnosis of isolated weight loss--a relatively frequent problem in internal medicine.

Thyroid disease

Diagnosis starts with a history and physical examination. Screening for thyroid disease in patients without symptoms is a debated topic although commonly practiced in the United States. If dysfunction of the thyroid is suspected, laboratory tests can help support or rule out thyroid disease. Initial blood tests often include thyroid-stimulating hormone (TSH) and free thyroxine (T4). Total and free triiodothyronine (T3) levels are less commonly used. If autoimmune disease of the thyroid is suspected, blood tests looking for Anti-thyroid autoantibodies can also be obtained. Procedures such as ultrasound, biopsy and a radioiodine scanning and uptake study may also be used to help with the diagnosis, particularly if a nodule is suspected.

[First diagnosis of celiac disease in a 67-year old female patient].

A 67 year old female patient presented herself to our emergency room with paraesthesia in both hands, chronic diarrhea and continuous weight loss. From the past medical history, only an autoimmune hypothyroidism was known. On initial, examination leading features were carpopedal spasms and a pulse deficit. Her general condition, especially the nutritional status was low. Serum levels of potassium (2.2 mmol/l) and calcium (1.45 mmol/l) were low, as well as the levels of total protein (5.1 g/dl) and albumin (2.94 g/dl). Clotting time was prolonged (Quick 51%). The ECG showed a ventricular bigeminus and a prolonged QT-period (120% rel). Endoscopy and biopsy showed a total villous atrophy suggesting celiac disease as probable cause. This was emphasized by the high antibody levels against gliadin (1:80) and endomyosin (1:40). Furthermore, the Human Leukocyte Antigen molecules HLA-B8 and HLA-DR3 showed increased expression. After normalizing the electrolyte imbalance intravenously the neurological symptoms disappeared as well as the arrhythmia. The QT-period went back to normal. Under initial drip feeding and a strict gluten-free diet the general condition improved quickly and the diarrhea stopped. A follow-up investigation 3 months later showed the woman in a good condition having gained 10 kg weight and an improvement in histological findings, so that diagnosis of celiac disease could be proved. The possibility of ventricular arrhythmia and a prolonged QT-period in the ECG should be taken into account for patients diagnosed with celiac disease, especially in case of electrolyte imbalance. In these cases addition to a strict gluten free diet a rapid correction of the electrolyte imbalance is necessary because of the risk of sudden cardiac death. Furthermore associated disorders like autoimmune diseases expressing the same HLA-antigens (HLA-B8 and HLA-DR3) must be considered. Combined incidence of celiac disease and autoimmune hypothyroidism is well documented. For patients with celiac disease we therefore recommend a routine testing of thyroid hormone levels.

Hypothyroidism

Diagnosis Laboratory testing of thyroid stimulating hormone levels in the blood is considered the best initial test for hypothyroidism; a second TSH level is often obtained several weeks later for confirmation. Levels may be abnormal in the context of other illnesses, and TSH testing in hospitalized people is discouraged unless thyroid dysfunction is strongly suspected, as the cause of the acute illness. An elevated TSH level indicates that the thyroid gland is not producing enough thyroid hormone, and free T4 levels are then often obtained. Measuring T3 is discouraged by the AACE in the assessment for hypothyroidism. In England and Wales, the National Institute for Health and Care Excellence (NICE) recommends routine T4 testing in children, and T3 testing in both adults and children if central hypothyroidism is suspected and the TSH is low. There are a number of symptom rating scales for hypothyroidism; they provide a degree of objectivity but have limited use for diagnosis.

'Great tan but I feel awful'. Diagnosis: Autoimmune primary hypoadrenalism.

'Everyone says I look great but I feel awful. I've lost weight, I feel sick all the time, I don't have any energy and I struggle just to get through the day'. Andrew is lean and tanned, but he has lost 8 kg since his last visit 3 months ago. He seems a bit flat in mood and listless in manner. He doesn't have a temperature, his blood pressure (BP) is 105/65, and examination of his chest and abdomen is normal. When the results of Andrew's tests come back the following day you are surprised to see abnormalities in his electrolytes.

Choosing Wisely Canada

A quality improvement initiative based on CWC principles was launched under the supervision of Dr. Danielle Martin at the Women's College Hospital (WCH) in Toronto. The American Thyroid Association and Choosing Wisely Canada recommends testing only Thyroid Stimulating Hormone (TSH) levels rather than testing both TSH and free thyroid hormones (such as T4) for assessment of suspected hypothyroidism, since majority of patients with hypothyroidism will present with abnormal TSH levels. A baseline audit at Women's College Hospital revealed that 60% of all free thyroid hormones tests were performed in patients who had normal TSH levels, amounting to approximately $50,000 annually in additional laboratory testing expenditure. A "Reflex T4" approach was implemented at WCH, wherein free T4 tests would not be conducted unless TSH levels are abnormal, or if there are clinical indications of situations when measurement of free thyroid hormones would be necessary. When it is found that TSH levels

Electrocardiograms Revealing Epsilon Waves Following Use of Hormone Supplements in Young Cardiac Arrest Patient.

An underlying cardiomyopathy should be suspected in young patients presenting with ventricular arrhythmias and sudden cardiac arrest. Electrocardiograms revealing epsilon waves are associated with many serious conditions such as arrhythmogenic right ventricular cardiomyopathy, posterior myocardial infarction, right ventricular infarction, infiltration disease, sarcoidosis, Brugada Syndrome, Tetralogy of Fallot, and hypothermia. This case report features epsilon waves in a young cardiac arrest patient suspected of having an unrecognized cardiomyopathy that resulted in a fatal arrhythmia in the setting of exogenous bovine thyroid hormone and steroid use.  Case presentation: A previously healthy 33-year-old male with a history of anabolic steroid use and bovine thyroid hormone use presented to the emergency department following witnessed cardiac arrest with bystander cardiopulmonary resuscitation (CPR). Upon emergency medical service (EMS) arrival, the patient was in ventricular fibrillation and received defibrillation with the return of spontaneous circulation. In the emergency department, he was unresponsive and required norepinephrine to maintain blood pressure. An epsilon wave and a prolonged QTc interval were noted on his electrocardiogram (ECG). CT angiogram of the chest and CT head were negative for acute abnormalities. Pertinent laboratory work-up included a lactate level of 12.0 mmol/L, thyroid-stimulating hormone of 0.02 ulU/L, and a free thyroxine level of 0.04 ng/dL. Cardiac ultrasound showed globally decreasedleft ventricular function with an ejection fraction of 25-30% and mild dilation of the right ventricle. A cardiac MRI was ordered but the patient had recurrent ventricular fibrillation and was too unstable to complete. He suffered anoxic brain injury with no improvements in neurologic function and was transitioned to comfort care. The patient died two months later in hospice care. The cause of cardiac arrest was attributed to the patient's steroid and bovine thyroid supplementation, but autopsy results revealed histologic evidence of possible arrhythmogenic right ventricular cardiomyopathy.  Discussion: Epsilon waves are widely known to be associated with structural abnormalities of the heart, most notably, arrhythmogenic right ventricular cardiomyopathies. Epsilon waves may be present in a variety of other medical conditions including posterior myocardial infarction, right ventricular infarction, infiltration disease, sarcoidosis, Brugada Syndrome, Tetralogy of Fallot, and hypothermia. This case report describes an epsilon wave found in a patient with suspected arrhythmogenic right ventricular cardiomyopathy that suffered a fatal arrhythmia triggered by bovine thyroid hormone and steroid use.

[Hyperthyroidism: diagnosis (author's transl)].

In hyperthyroidism we differentiate two main forms: (1) hyperthyroidism due to Basedow's (Graves') disease, always characterized by endocrine eye signs, frequently with goiter; (2) hyperthyroidism due to nodular goiter or to Plummers' disease, without endocrine exophthalmos. The clinical diagnosis includes typical complaints (e.g., weight loss, heat intolerance, sweating) and findings (e.g., tachycardia, tremor, soft-warm skin). The technical diagnosis includes in vivo (scintigraphy, RI-uptake, X-ray examination) and in vitro (T3-RIA, T4-assay, TRH response to TRH) tests.

InternalMed_Harrison

Screening tests for thyroid disease can include anti–thyroid peroxidase (TPO) or anti-thyroglobulin autoantibodies or anti-TSH receptor antibodies for Graves’ disease. Yearly measurements of TSH can then be used to follow these individuals. Celiac disease can be screened for using the anti–tissue transglutaminase (tTg) antibody test. For those <20 years of age, testing every 1–2 years should be performed, whereas less frequent testing is indicated after the age of 20 because the majority of individuals who develop celiac disease have the antibody earlier in life. Positive tTg antibody test results should be confirmed on repeat testing, followed by small-bowel biopsy to document pathologic changes of celiac disease. Many patients have asymptomatic celiac disease that is nevertheless associated with osteopenia and impaired growth. If left untreated, symptomatic celiac disease has been reported to be associated with an increased risk of gastrointestinal malignancy, especially lymphoma.

Positive tissue transglutaminase antibodies with negative endomysial antibodies: low rate of celiac disease.

Screening for celiac disease is based on the sequential evaluation of serologic tests and intestinal biopsy; an optimal screening protocol is still under investigation. The screening policy of one of the main healthcare providers in Israel (Maccabi) consists of measuring total immunoglobulin A and tissue transglutaminase IgA antibodies and confirming positive results by endomysial antibodies. For IgA-deficient patients antigliadin IgG is measured. To evaluate the use of tTGA as a first-level screening test in patients suspected of having celiac disease The results of tTGA and EMA tests over a 3 month period were obtained from the laboratory computer. Letters were sent to the referring physicians of patients with positive tests, requesting clinical information and small intestinal biopsy results. tTGA was performed using an anti-guinea pig tTG-IgA enzyme-linked immunosorbent assay kit. Overall, 2,505 tTGA tests were performed: 216 (8.6%) were tTGA-positive of which 162 (75%) were EMA-negative (group 1) and 54 (25%) EMA-positive (group 2.) Clinical information was obtained for 91 patients in group 1 and 32 in group 2. Small intestinal biopsy was performed in 33 (36%) and 27 patients (84%) in groups 1 and 2, respectively. Celiac disease was diagnosed in 4 biopsies (12%) in group 1 and 23 (85%) in group 2 (P < 0.0001). The positive predictive value was 45% for tTGA and 85% for EMA. Symptomatic patients with positive tTGA and negative EMA have a low rate of celiac disease compared to those who are tTGA-positive and EMA-positive. Confirmation with EMA is advised when tTGA is performed as a first-level screening for suspected celiac disease.

[Heart involvement in anorexia nervosa: an electrocardiographic, functional and morphological study].

Mental anorexia (MA) is the most frequent condition of malnutrition in industrialized countries. Sudden death in MA is not infrequent. Furthermore, the role of nutritional state as an important determinant of myocardial function is known. Cardiovascular function was studied in 9 patients with MA. Blood electrolytes and thyroid function were assessed, basal and dynamic ECG, chest roentgenogram, M-mode echocardiography, ergometric test, cardiac output measurement and, in two cases, magnetic nuclear resonance (MNR) were performed. Our data confirm the ECG changes which were preeminent in the clinical context, as predictors of possible major, life-threatening arrhythmic events. The correct QT interval was normal in all patients. In 4 cases with heart rate less than 40 b/min, Holter ECG showed ventricular and atrial extrasystolic beats. In one case S-A blocks with idioventricular substitutive beats were recorded; the normal performance under maximal strain stands for a normal functional reserve. Blood electrolytes were in the normal range. The hypothalamic-pituitary axis can be considered as a cocausal factor by means of autonomic nervous system modulations. Echocardiography revealed only a mild reduction of ventricular wall thickness. Scattered degenerative myocardial involvement as shown by MNR imaging, could be the anatomical counterpart of a clinically emerging cardiomyopathy with potentially severe arrhythmias.

[Thyroid dysfunction in women with suspected fibromyalgia].

Due to its prevalence, morbidity, and frequency rate, fibromyalgia (FM) represents a health problem and produces high healthcare resource utilization. Serum thyrotropin (TSH) measurement is recommended as a first-line laboratory test to exclude hypothyroidism as a cause of FM syndrome. The aim of this study was to analyze the prevalence of thyroid dysfunction (TD), the frequency of TSH measurement, the effect of levothyroxine treatment, and whether screening for TD is justified in women with suspected FM. A cross-sectional descriptive study was performed in 400 consecutive female outpatients with suspected FM and in 384 controls from January 2001 to October 2004. TSH measurement was used as the first line test to detect TD. The prevalence of TD in patients with suspected FM (40/400; 10%; 95% CI: 7-13%) and controls was similar (46/384; 12%; 95% CI: 9-15%). No differences were found in the types and grades of TD. The prevalence of TD was higher in patients with suspected FM and connective tissue diseases (12%) than in those without these diseases (5%). The most frequent TD was subclinical hypothyroidism (5.5% in suspected FM and 6.7% in controls), and in 93% of these cases TSH concentrations were <10 mIU/L. FM persisted in all women with hypothyroidism even after euthyroidism was achieved with levothyroxine. A total of 870 TSH determinations were performed in 360 euthyroid patients with suspected FM. The prevalence of TD in women with suspected FM does not differ from that in the general population. Screening for TD does not appear to be justified in women without diseases that increase their risk. In many cases the request for thyroid function tests is excessive. Treatment for hypothyroidism does not affect FM.

Pituitary Hyperplasia in Primary Hypothyroidism -- History and Physical

The physical examination needs to include a head-to-toe approach. Starting with the head, inspect for typical facies such as a "peaches and cream" complexion or loss of the lateral third of the eyebrow in those with hypothyroidism. A comprehensive eye examination should be performed, inspecting for periorbital edema, including testing visual fields and performing fundoscopy. Neck examination should include examining the thyroid for goiter or palpable nodules. Examining the extremities should include looking for dry skin, nail changes such as onycholysis or brittle nails, proximal muscle weakness, and checking reflexes that can show a delayed relaxation in patients with hypothyroidism. Moving on to the chest, the clinician should evaluate for breast discharge, check the pulse for an irregularly irregular rhythm suggestive of atrial fibrillation, or bradycardia in severe hypothyroidism, evaluate for a very soft or inaudible heart sounds that may suggest the presence of a pericardial effusion and finally check for reduced breath sounds at the lung base with dullness to percussion that may suggest the presence of a pleural effusion. For children specifically, the clinician should include the height and weight growth charts, calculation of body mass index (BMI), and Tanner classification.

Diagnostic utility of coeliac disease: a descriptive study in a tertiary care hospital, oman.

The prevalence of coeliac disease in Oman is unknown. We aim to estimate the prevalence of coeliac disease in at-risk subjects, describe the clinical characteristics and laboratory findings associated with coeliac disease and the validity of serological testing for coeliac disease at the Royal Hospital, Oman over a period of three years. This is a retrospective case finding study. The medical and laboratory records were reviewed for patients for whom serum antiendomysium IgA antibodies were requested at the Royal Hospital during a 3-year period (1(st) Jan 2006-31(st) Dec 2008). The data were extracted in order to assess the following: a) Prevalence rate of coeliac disease among at-risk subjects; b) Clinical characteristics in patients with coeliac disease and clinical manifestations for which the requesting clinicians considered coeliac disease as a possible diagnosis, including their specialties; c) Laboratory tests results in patients with coeliac disease; and d) Validity of antiendomysium antibodies testing in comparison with histopathology of jejunal biopsies for diagnosing coeliac disease. The study included 431 patients (250 females, 181 males) who were suspected of having (or screened for) coeliac disease. The median of age was 15 years (range: 9 months-74 years) with mean ± SD 18.95 ± 14.1 years. Of these, 15 (3.5%) patients (10 females, 5 males) with a median age of 19 years and mean 21.4 ± 13.0 years (range: 2.5-38 years), had positive antiendomysium antibodies results with median (range) of 160 (40-320) IU/L and mean± SD 204.5 ± 160 IU/L. Of these 15 patients, 13 had positive jejunal histopathological changes indicative of coeliac disease; the remaining 2 patients had no biopsy examination. Of the 44 patients with negative antiendomysium antibodies <10 IU/L who had jejunal biopsy, 41 were negative and 3 had histopathological changes suggestive of mild coeliac disease. All the 3 patients had serum total IgA levels within the reference range. The calculated validity indicators for antiendomysium antibodies were: sensitivity 81.3%, specificity 100%, positive predictive value 100%, negative predictive value 93.2% and efficiency 94.7%. The most common mode of presentation in patients with coeliac disease was gastrointestinal features, type 1 diabetes mellitus, anemia, short stature and hypothyroidism. The seropositivity in tye 1 diabetics was 4.9%. Investigations for coeliac disease were most frequently made by endocrinologists (pediatric and adult) who accounted for 53.8% followed by gastroenterologists (pediatric and adult) with 40.6% with less consideration by the other clinicians (5.6%). The availability of highly specific and sensitive serological test and increased awareness for coeliac disease among some medical specialties has increased the number of diagnosed cases of coeliac disease. The requesting for serological test is being made mainly by endocrinologists and gastroenterologists.

Failure to thrive

Based on the information gained from the history and physical examination, a workup can then be conducted, in which possible sources of FTT can be further probed through blood work, x-rays, or other tests. Laboratory workup should be done in response to specific history and physical examination findings. Medical providers should take care not to order unnecessary tests, especially given estimates that the usefulness of laboratory investigations for children with failure to thrive is 1.4%. Initial bloodwork may include a complete blood count (CBC) with differential to see if there are abnormalities in the number of blood cells, a complete metabolic panel to look for electrolyte derangements, a thyroid function test to assess thyroid hormone activity, and a urinalysis to test for infections or diseases related to the kidneys or urinary tract. If indicated, anti-TTG IgA antibodies can be used to assess for celiac disease, and a sweat chloride test can be used to screen for cystic

Liver failure unmasks celiac disease in a child.

Liver involvement in celiac disease (CD) varies from asymptomatic mild non-specific hepatitis to liver failure. Here we report the first child with liver failure due to a sclerosing cholangitis associated with CD. An 11 year old girl presented with fatigability for 1 year and jaundice and abdominal distension for 3 weeks. On examination, the growth parameters were below 3rd percentile; she had splenomegaly and severe ascites. Liver function tests revealed elevated liver enzymes (ALT 84 U/L, total bilirubin 98.7 μmol/L, and direct 58.3 μmol/L, gamma-glutamyltransferase 111 U/L, INR 2.7, and albumin 16 g/L). Extensive investigations excluded infectious, metabolic, structural, and endocrine causes of chronic liver disease. Because of the short stature and anemia, CD was suspected, and serological evaluation revealed increased IgA antibodies to tissue transglutaminase (385 units; normal, 0-20 units). Histopathological examination of small intestinal biopsies showed total villous atrophy consistent with celiac disease. Liver biopsy showed bridging fibrosis, portal tract expansion by lymphocytes, plasma cells, and neutrophils, bile ductular proliferation, and periductular fibrosis. Magnetic resonance cholangiography revealed beading and narrowing appearance of intra- and extrahepatic bile ducts. The histopathological and imaging findings are diagnostic of sclerosing cholangitis. The child was initiated on ursodeoxycholic acid, gluten free diet for life, and steroid that was tapered over 3 months. At 3 month follow up, liver function tests completely normalized. CD is a potentially treatable cause of liver failure. All patients with severe unexplained liver disease should undergo serological screening for CD.

[Diagnosis of thyreopatic diseases by laboratory examinations--possibility for rational economy].

This paper is oriented on the possibility of racional economy of laboratory diagnostical process of thyreopathies. The study was based on analysis of 29,683 examinations made at biochemical department in hospital Trencín. The overuse--mostly of antibodies and also, but less of thyreoidal hormones was discovered, mostly in the group of physicians in general practise and less in hospital and internal practise. The absence of initial algoritmus in thyreoidology is documented. The followed approach was formulated as new proposal: the first step is the examination of TSH (by ultrasensitive method) with possibility for all groups of physicians. Clinical and biochemical department should have responsibility to add fT4 in the case of pathological TSH. The endokerinologist should have responsibility for all other thyreoidal examinations, but in reasonable case also the internists in ambulatory and hospital care, and other relevant hospital physicians could order these examinations. Probability of cost saving was about 34% of expanditures on thyreoidology. To make the recount for Slovak republic the saving cost could be about 42,500,000 Sk.

Gluten-related disorders

Diagnosis A literature review of 2014 found that non-coeliac gluten sensitivity diagnosis can be reached only by excluding celiac disease (CD) and wheat allergy. Persons suspected of having celiac disease may undergo serological testing for IgA anti-tissue transglutaminase antibodies (abbreviated anti-tTG antibodies or anti-TG2 antibodies) and anti-endomysial antibodies (abbreviated EMA) provided the IgA-level is high, and if IgA is low, testing for certain IgG antibodies; in case of positive serological indication, a duodenal biopsy may confirm active celiac disease.

Hypothyroidism -- History and Physical

A careful physical examination may reveal some clues since the signs of hypothyroidism are very subtle. Physical examination may be significant for the following: Enlarged thyroid gland Weight gain The slowness of speech and movements Dry skin Coarse and brittle hair Pallor and jaundice Dull facial expressions Macroglossia Bradycardia Pericardial effusion Prolonged ankle reflex relaxation time [2] However, most of the patients have normal thyroid examinations.

Failure to Thrive -- Evaluation

In patients who are ill-appearing, have severe weight loss or other red flags suggesting underlying organic medical conditions, have not gained weight with initial dietary interventions, or in patients where follow-up cannot be ensured, an initial laboratory evaluation is warranted. [17] If not done previously, observing a feed and formula preparation, if applicable, is a helpful assessment in younger infants. Laboratory evaluation should screen for the most likely organic causes based on the patient's history and physical examination. Results may guide the clinician to more specific tests if needed. Initial labs include a complete blood count (CBC) to assess for anemia, an iron panel because the most common type of anemia in this age group is iron deficiency, and a metabolic panel to assess electrolyte and hydration status and liver and kidney function. If there is a concern for severe malnutrition and risk of refeeding syndrome, the metabolic panel should include a baseline phosphorus and magnesium level in addition to the standard electrolytes included on the basic metabolic panel. [24] An erythrocyte sedimentation rate (ESR) can be useful to identify nonspecific underlying inflammation. [5] Assessing thyroid function with thyroid-stimulating hormone (TSH) and free T4 should be considered. Ensure a normal newborn metabolic screen is documented; if not, sending one can provide clues to less common organic causes of FTT, such as inborn errors of metabolism. A urinalysis and urine culture help assess for kidney diseases and screen for a common chronic infection. If there is a prominent history of abnormal stool patterns or blood/mucus in the stool, obtain stool studies including culture, guaiac, fecal calprotectin, and reducing substances. A celiac panel including tissue transglutaminase immunoglobulin A (IgA) and total IgA may also be helpful if the patient is experiencing gastrointestinal symptoms. [5] Low prealbumin can be a marker of more severe malnutrition, although consensus on its clinical utility remains lacking. [25] Pending results of the first set of basic labs, more specific labs may be indicated, such as a chloride sweat test, pancreatic function testing, or other metabolic-specific testing such as an ammonia level. While imaging is not routinely indicated initially, a chest radiograph, ECG, abdominal radiograph, and an upper GI series may be useful if the patient has a positive review of systems. In consultation with pediatric subspecialists, endoscopy or echocardiography may be warranted if other findings are concerning for underlying disease within these body systems. [4]

Neonatal hypothyroidism detected by the Northwest Regional Screening Program.

The Northwest Regional Screening Program to detect congenital hypothyroidism in infants born in Oregon, Montana, Alaska, and Idaho (combined birthrate of 69,000/ yr) was added to our ongoing screening program in 1975. The program utilizes dried blood filter paper specimens collected routinely in the first few days of life in all four states and again at about 6 weeks of age in Oregon only. The screening test consist of an initial thyroxine (T4) measurement; a thyroid-stimulating hormore (TSH) determination is performed on those specimens with T4 concentrations in the lowest 3% group. Serum samples obtained by venipuncture are requested for confirmation of the diagnosis. In the first two years of the program, 25 infants with primary hypothyroidism were detected amont 110,667 infants screened, a frequency of 1:4,430. Fourteen cases of thyroxine-binding globulin deficiency were also detected, a frequency of 1:7,900. Using the T4 followed by TSH testing approach, the frequency of request for repeat specimens was 0.4% in Oregon and 0.05% in the other states. The cost per specimen was $1.96. The majority of infants lacked clinical signs or symptoms of hypothyroidism; only one infant was clinically suspected of having hypothyroidism prior to detection. The most common neonatal symptoms were constipation, lethargy, and prolonged jaundice, while the most common physical signs were hypotonia, umbilical hernia, and large fontanels. Thyroid scans showed the most common etiology to be thyroid aplasia, followed by an ectopic gland, hypoplasia, and goiter. Serum T4 concentrations were lowest in those infants with aplasia, intermediate in infants with an ectopic gland or hypoplasia, and normal in the infant with the goiter. Neonatal hypothyroidism varies in degree and has several different causes; the capacity to secrete thyroid hormone, the duration before hypothyroidism becomes clinically manifest, and possibly the eventual prognosis for intellectual function depend on the nature of the underlying cause. While the mean age at treatment was 59 days, the goal of diagnosing congenital hypothyroidism and treating affected infants by 1 month of age seems realistic.

[Involuntary weight loss].

Involuntary weight loss is a clinical situation with unknown incidence, significance and prognosis. We present a retrospective study of 68 patients hospitalized due to involuntary weight loss. The most frequent individual cause was neoplasia; however, globally, non-neoplastic causes were most frequent. None of the symptoms was significantly associated to the diagnosis of a neoplastic or non-neoplastic disease. The mean age of the patients with neoplasia (71.36 +/- 17.19) differed from the mean age of the patients without neoplasia (63.39 +/- 17.19 years) (p < 0.05). The patients with neoplastic and infectious diseases needed a higher number of analysis than the other patients, being the most valuable data the presence of anemia, cholestasis and determination of thyroid hormones. The most useful evaluations were clinical and endoscopical assessments, thoracic radiography and abdominal echography.

Thyrotoxicosis -- Differential Diagnosis

Most patients will present with symptoms of fatigue, palpitations, weight loss, diaphoresis, heat intolerance. These patients are generally stable for outpatient workup for the underlying etiology.  A careful history and physical exam can aid in the diagnosis, but further laboratory studies and imaging is often warranted.

Justification of whole-body CT in polytrauma patients, can clinical examination help selecting patients?

Whole-body computed tomography (WBCT) is used indiscriminately in trauma cases, just on the suspicion of them being polytrauma cases. A good clinical examination done pre-emptively could prevent the need for this investigation and its undesirous effects. We did this study with an overall aim to assess, if WBCT can be limited to subgroup of trauma patients without compromising clinical safety. Retrospective database analysis of 150 cases of polytrauma who underwent WBCT in 2017 was performed. We recorded age, gender, radiation dose and CT findings in all cases and calculated mean age, number of total patients and female patients less than 25 years of age, number of normal WBCT scans, mean radiation dose in the normal and total scans. We also compared pre-test clinical requests with whole-body CT findings, and categorised them in following seven categories: Category 1-Normal Scans; Category 2-Clinically expected Major Injuries; Category 3-Clinically expected Minor Injuries (low risk injuries with no risk of morbidity or mortality if remained undiagnosed), Category 4-Clinically expected CT findings with unexpected Minor (non-serious) injuries; Category 5-Clinically expected CT findings with unexpected Major (serious) injuries, Category 6-Unexpected Minor (non-serious) injuries; Category 7-Unexpected Major (serious) injuries. Categories 2 &3 of clinically expected major and minor injuries included patients with fewer injuries than expected. On the other hand, Category 4 & 5 consist of clinically expected findings with other unexpected injuries, including minor and major injuries respectively. Body injuries were reported in seven areas as per our institutional reporting protocol- Head (including face), Cervical Spine, Thoracolumbar Spine, Chest, Abdomen, Pelvis and Appendicular Skeleton (if asked for). Overall, we found statistically significant correlation between clinical suspicion raised and WBCT findings with good clinical correlation noticed in 106 (70.66%) cases (including 61 cases of clinically suspected major injuries, 15 cases of clinically suspected minor injuries and 25 nearly normal scans with no obvious clinical concern). Isolated unexpected serious injury without any clinical suspicion was seen in only 1 case. Surprisingly, 25 scan requests were made due to high risk mechanism of injury with no obvious clinical concern and were found normal in 20 cases and showed very subtle injuries in 5. Notably, 30 cases of expected major and minor injuries showed highly accurate clinical findings with no injury other than the region of concern and in these cases, limited scan requests would have been sufficient. Mean radiation dose of the entire study group was 22.45 mSv and those to normal patients was 21.19 mSv. This study re-emphasizes the significance of good clinical examination in the era of evidence based medicine, which would reduce the high number of unnecessary high dose WBCT (25 scans with no positive findings on clinical examination were nearly normal and in 30 cases limited CT would have been sufficient), thereby, decreasing radiation exposure and its potential side effects on polytrauma patients without affecting their survival.


Chronic hypertension. This is hypertension that is detected before pregnancy or before the 20th week of pregnancy and/or persists at 12 weeks postpartum.

A pregnant woman, 10 weeks pregnant, comes to the emergency room with a blood pressure of 160/105 mmHg. She is in good general condition, with only mild headache, which is the reason for taking her blood pressure. After 4 hours of rest she presented with a blood pressure of 150/95mmHg. A complete blood count is normal and proteinuria is negative. What type of hypertension does she have?

Hypertensive disease of pregnancy

Preeclampsia superimposed on chronic hypertension occurs when a pregnant woman with chronic hypertension develops signs of pre-eclampsia, typically defined as new onset of proteinuria ≥30 mg/dL (1+ in the dipstick) in at least 2 random urine specimens that were collected ≥4 h apart (but within a 7-day interval) or 0.3 g in a 24-h period. Like ordinary pre-eclampsia, superimposed pre-eclampsia can also occur with severe features, which are defined as: systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥110 mmHg despite escalation of antihypertensive therapy; thrombocytopenia (platelet count <100,000/microL); impaired liver function; new-onset or worsening renal insufficiency; pulmonary edema; or persistent cerebral or visual disturbances. As a result, superimposed pre-eclampsia can be diagnosed without proteinuria when a sudden increase in previously well-controlled blood pressure is accompanied by severe features of pre-eclampsia.

Eclampsia

Vital signs One of the core features of pre-eclampsia is high blood pressure. Blood pressure is a measurement of two numbers. If either the top number (systolic blood pressure) is greater than 140 mmHg or the bottom number (diastolic blood pressure) is greater than 90 mmHg, then the blood pressure is higher than the normal range and the person has high blood pressure. If the systolic blood pressure is greater than 160 or the diastolic pressure is greater than 110, the hypertension is considered to be severe. Laboratory testing Another core feature of pre-eclampsia is proteinuria, which is the presence of excess protein in the urine. To determine if proteinuria is present, the urine can be collected and tested for protein; if there is 0.3 grams of protein or more in the urine of a pregnant woman collected over 24 hours, this is one of the diagnostic criteria for pre-eclampsia and raises the suspicion that a seizure is due to eclampsia.

Home blood-pressure monitoring in a hypertensive pregnant population.

The majority of patients with chronic or gestational hypertension do not develop pre-eclampsia. Home blood-pressure monitoring (HBPM) has the potential to offer a more accurate and acceptable means of monitoring hypertensive patients during pregnancy compared with traditional pathways of frequent outpatient monitoring. The aim of this study was to determine whether HBPM reduces visits to antenatal services and is safe in pregnancy. This was a case-control study of 166 hypertensive pregnant women, which took place at St George's Hospital, University of London. Inclusion criteria were: chronic hypertension, gestational hypertension or high risk of developing pre-eclampsia, no significant proteinuria (≤ 1+ proteinuria on dipstick testing) and normal biochemical and hematological markers. Exclusion criteria were maternal age < 16 years, systolic blood pressure > 155 mmHg or diastolic blood pressure > 100 mmHg, significant proteinuria (≥ 2+ proteinuria on dipstick testing or protein/creatinine ratio > 30 mg/mmol), evidence of small-for-gestational age (estimated fetal weight < 10<supth</sup centile), signs of severe pre-eclampsia, significant mental health concerns or insufficient understanding of the English language. Pregnant women in the HBPM group were taught how to measure and record their blood pressure using a validated machine at home and attended every 1-2 weeks for assessment depending on clinical need. The control group was managed as per the local protocol prior to the implementation of HBPM. The two groups were compared with respect to number of visits to antenatal services and outcome. There were 108 women in the HBPM group and 58 in the control group. There was no difference in maternal age, parity, body mass index, ethnicity or smoking status between the groups, but there were more women with chronic hypertension in the HBPM group compared with the control group (49.1% vs 25.9%, P = 0.004). The HBPM group had significantly fewer outpatient attendances per patient (6.5 vs 8.0, P = 0.003) and this difference persisted when taking into account differences in duration of monitoring (0.8 vs 1.6 attendances per week, P < 0.001). There was no difference in the incidence of adverse maternal, fetal or neonatal outcome between the two groups. HBPM in hypertensive pregnancies has the potential to reduce the number of hospital visits required by patients without compromising maternal and pregnancy outcomes. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Gestational hypertension

Diagnosis Conditions There exist several hypertensive states of pregnancy: Gestational hypertension Gestational hypertension is usually defined as having a blood pressure higher than 140/90 measured on two separate occasions, more than 6 hours apart, without the presence of protein in the urine and diagnosed after 20 weeks of gestation. Pre-eclampsia Pre-eclampsia is gestational hypertension plus proteinuria (>300 mg of protein in a 24-hour urine sample). Severe pre-eclampsia involves a blood pressure greater than 160/110, with additional medical signs and symptoms. HELLP syndrome is a type of pre-eclampsia. It is a combination of three medical conditions: hemolytic anemia, elevated liver enzymes and low platelet count. Eclampsia This is when tonic-clonic seizures appear in a pregnant woman with high blood pressure and proteinuria. Pre-eclampsia and eclampsia are sometimes treated as components of a common syndrome. Treatment

Gestational hypertension

Gestational hypertension or pregnancy-induced hypertension (PIH) is the development of new hypertension in a pregnant woman after 20 weeks' gestation without the presence of protein in the urine or other signs of pre-eclampsia. Gestational hypertension is defined as having a blood pressure greater than 140/90 on two occasions at least 6 hours apart. Signs and symptoms No single diagnostic test currently exists to predict the likelihood of developing gestational hypertension. High blood pressure is the major sign in diagnosing gestational hypertension. Some women with gestational hypertension may present asymptomatic, but a number of symptoms are associated with the condition. Symptoms Edema Sudden weight gain Blurred vision or sensitivity to light Nausea and vomiting Persistent headaches Increased blood pressure

Pre-eclampsia

Immune factors may also play a role. Diagnosis Testing for pre-eclampsia is recommended throughout pregnancy via measuring a woman's blood pressure. Diagnostic criteria Pre-eclampsia is diagnosed when a pregnant woman develops: Blood pressure ≥140 mmHg systolic or ≥90 mmHg diastolic on two separate readings taken at least four to six hours apart after 20 weeks' gestation in an individual with previously normal blood pressure. In a woman with essential hypertension beginning before 20 weeks' gestational age, the diagnostic criteria are an increase in systolic blood pressure (SBP) of ≥30 mmHg or an increase in diastolic blood pressure (DBP) of ≥15 mmHg. Proteinuria ≥ or more of protein in a 24-hour urine sample or a SPOT urinary protein to creatinine ratio ≥0.3 or a urine dipstick reading of 1+ or greater (dipstick reading should only be used if other quantitative methods are not available).

Hypertensive disease of pregnancy

Preeclampsia can also be diagnosed if a woman has both increased blood pressure and 1 or more signs of significant organ damage. Signs of significant organ damage include: Severely elevated blood pressure (blood pressure > 160/110) Thrombocytopenia Increased or rapidly elevating levels of creatinine in the blood Increased liver enzymes Pulmonary edema New or persistent headaches that do not respond to pain medication Blurred or altered vision If a woman with preeclampsia has any of these signs of significant organ damage, then her condition is classified as preeclampsia with severe features. This diagnosis can be made even if the patient does not have proteinuria. Women with preeclampsia with severe features are encouraged to deliver the child after 34 weeks of gestation to minimize the risks of the severe complications. Preeclampsia can also present with seizures in the pregnant mother. In this case, the patient would be diagnosed with eclampsia.

Transient gestational hypertension and pre-eclampsia: Two case reports and literature review on the need for stringent monitoring.

Transient gestation hypertension is a contributor to adverse pregnancy outcomes particularly when it progresses to pre-eclampsia (PE). This requires frequent monitoring. We illustrate the need for stringent monitoring of gestational hypertension, transient gestational hypertension (TGH) and PE without severe features and conducted a brief rapid review of the literature. Two cases are presented: Firstly, a 25-year-old primigravida at 30 gestational weeks who had an isolated TGH with high blood pressure (BP) of 141/87 mmHg, which was not investigated. Four weeks later, she presented with a BP of 202/128 mmHg, imminent eclampsia and intrauterine foetal death and had an uncomplicated induction of labour and delivered a 1400 g macerated male stillborn. Secondly, a 30-year-old primigravida at 30 gestational weeks who developed PE but her monitoring was compromised initially by inadequate healthcare capacity including unavailability of hospital bed-space for inpatient care and later by poor clinic attendance as a result of poor finances. At 32 gestational weeks, she presented with decreased foetal movement and was diagnosed as haemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome and intrauterine foetal death. She was stabilised, had induction of labour and delivered a 1400 g male macerated stillborn. Thereafter, the need for her to go home to complete the cultural burial rites of her baby and the pressure from her workplace resulted in an inadequate postpartum follow-up care. In conclusion, transient gestational hypertension is associated with adverse maternal and foetal outcomes, including foetal demise. Unavailability of hospital bed-space and poor personal finances interfere with stringent monitoring of hypertensive disorders and can be associated with adverse pregnancy outcomes. Stringent laboratory monitoring in these cases is defined by the authors as testing at least blood levels of serum Creatinine, Haemoglobin concentration, Alanine transaminase and Platelet count (abbreviated as 'CHAP') weekly.

[Atypical preeclampsia and perinatal success: a case report].

Preeclampsia is a multi systemic syndrome of variable severity, pregnancy specific, consequence of an abnormal vascular response to placentation, with increase in peripheral vascular resistance, stimulation of platelet aggregation, activation of the coagulation cascade, and endothelial dysfunction. In the majority of cases, it will present with gestational hypertension and proteinuria, after 20 weeks, nevertheless, in other cases, it has presented as an atypical form (with absence of hypertension and/or proteinuria) behaving like severe preeclampsia. We report the case of a patient, 32 year old primigravida, with a 26.6 weeks gestation, that comes to the office with postprandial projectile vomiting. At the time of admission, she presents with sudden headache, phosphenes, and tinnitus, associated to epigastric pain, with a blood pressure of 110/70 mmHg; fetal heart rate of 146 bpm, normal lower limbs and reflexes. The Complete Blood Count and liver function tests are within normal values, urinalysis with proteinuria. Normal hepatic ultrasound. Obstetric ultrasound; with fetal measurements of 2.6 weeks below, with flattening of the growth curve, Doppler flowmetry with an increase in placental resistance and oligohydramnios. Given the clinical manifestations compatible with severe preeclampsia, magnesium sulfate, and antenatal corticosteroid therapy are initiated, and abdominal termination of pregnancy is decided. A female newborn is obtained, of 595 g, Apgar 4/7. On immediate puerperium, she presents with an increase in blood pressure of 150/90 mmHg, discharged with normal blood pressure 96 hours later. The newborn girl was discharged when she reached a weight of 2000 g. Today, she is neurologically unimpaired.

Hypertensive disease of pregnancy

Because chronic hypertension can progress to more severe forms of disease, it is important to accurately diagnose the condition early, ideally prior to pregnancy, and initiate management to control parental blood pressure. This is often difficult, as many reproductive individuals may not regularly visit the doctor and, when pregnant, may initially present for prenatal care in the second trimester. Pre-eclampsia and eclampsia Preeclampsia is a medical condition which usually develops after 20 weeks of gestation and traditionally involves both newly increased blood pressure (blood pressure > 140/90 mmHg) and proteinuria. Preeclampsia is a leading cause of fetal complications, which include low birth weight, preterm birth, and stillbirth. Women with preeclampsia are encouraged to deliver the child after 37 weeks of gestation to minimize the risks of the severe complications.

Does a predisposition to the metabolic syndrome sensitize women to develop pre-eclampsia?

This study aimed to identify those factors in the non-pregnant state that distinguished women who developed pre-eclampsia from those who had normotensive pregnancies. This was a retrospective analysis of anthropometry, blood pressure, biochemical and haematological variables in 62 women with pre-eclampsia and 84 normotensive pregnant women who took part in studies of the pathophysiology of pre-eclampsia. Pregnant volunteers were seen, after admission to hospital or in the outpatient clinic, and followed-up at 6 weeks and 6 months post-partum in the outpatient clinic or their home. Participants Proteinuric pre-eclampsia was defined as blood pressure > or = 140/90 mmHg with proteinuria of at least 300 mg/24 h after 20 weeks gestation, in women with no history of hypertension and whose blood pressure returned to normal levels by 6 months post-partum. Normotensive pregnancy was defined as blood pressure < 130/90 mmHg without proteinuria. The primary outcome measures were blood pressure, body mass index (BMI), triglycerides, total cholesterol, low density lipoprotein (LDL) and high density lipoprotein cholesterol and markers of severity of pre-eclampsia. Regardless of parity, women with pre-eclampsia had elevated BMI before, during and after pregnancy compared with women who had normotensive pregnancies. Triglycerides were significantly elevated in women who had pre-eclampsia both before and after delivery, while total and LDL cholesterol were elevated significantly at both visits after delivery. Systolic and diastolic blood pressure, which by definition were elevated antepartum in women with pre-eclampsia, remained higher at post-partum visits compared with women who had normotensive pregnancies. Women with pre-eclampsia reported a greatly increased frequency of both maternal hypertension and pre-eclampsia. Markers of severity of pre-eclampsia, which normalized by 6 months postpartum, included plasma creatinine, uric acid, albumin, endothelin 1 and urinary protein, 2,3, dinor-6-keto-PGF1alpha, blood platelet and neutrophil counts. The relative elevation of blood pressure, BMI and lipids in the non-pregnant state are features of the metabolic syndrome and may be important sensitizing factors contributing to the pathogenesis of pre-eclampsia. A familial predisposition to pre-eclampsia may operate partly through these mechanisms.

Pre-eclampsia

Suspicion for pre-eclampsia should be maintained in any pregnancy complicated by elevated blood pressure, even in the absence of proteinuria. Ten percent of individuals with other signs and symptoms of pre-eclampsia and 20% of individuals diagnosed with eclampsia show no evidence of proteinuria. In the absence of proteinuria, the presence of new-onset hypertension (elevated blood pressure) and the new onset of one or more of the following is suggestive of the diagnosis of pre-eclampsia: Evidence of kidney dysfunction (oliguria, elevated creatinine levels) Impaired liver function (noted by liver function tests) Thrombocytopenia (platelet count <100,000/microliter) Pulmonary edema Ankle edema (pitting type) Cerebral or visual disturbances

Obstentrics_Williams

C, FIGURE 40-1 Schematic shows normal reference ranges for mean arterial blood pressure changes across pregnancy. Patient A (blue) has mean blood pressures near the 20th percentile throughout pregnancy. Patient B (red) has a similar pattern with mean pressures at the 25th percentile until approximately 36 weeks when her blood pressure begins to rise. By term, it is substantively higher and in the 75th percentile, but she is still considered "normotensive." 25th percentile until 32 weeks. These begin to rise in patient B, who by term has substantively higher blood pressures. However, her pressures are still < 140/90 mm Hg, and thus she is considered to be "normotensive." We use the term delta hypertension to describe this rather acute rise in blood pressure. Some of these women will go on to have obvious preeclampsia, and some even develop eclamptic seizures or HELLP (hemolysis, devatedliver enzyme levels, low 2latelet count) syndrome while still normotensive.

Hypertensive emergency

Diagnosis The term hypertensive emergency is primarily used as a specific term for a hypertensive crisis with a diastolic blood pressure greater than or equal to 120 mmHg or systolic blood pressure greater than or equal to 180 mmHg. Hypertensive emergency differs from hypertensive urgency in that, in the former, there is evidence of acute organ damage. Both of these definitions had collectively been known as malignant hypertension, although this medical term is replaced. In the pregnant patient, the definition of hypertensive emergency (likely secondary to pre-eclampsia or eclampsia) is only a blood pressure exceeding 160 mmHg systolic blood pressure or 110 mmHg diastolic blood pressure.

Hypertensive disease of pregnancy

Risks Some women have a greater risk of developing hypertension during pregnancy. These are: Women with chronic hypertension (high blood pressure before becoming pregnant). Women who developed high blood pressure or preeclampsia during a previous pregnancy, especially if these conditions occurred early in the pregnancy. Women who are obese prior to pregnancy. Pregnant women under the age of 20 or over the age of 40. Women who are pregnant with more than one baby. Women with diabetes, kidney disease, rheumatoid arthritis, lupus, or scleroderma. Diagnosis There is no single test to predict or diagnose preeclampsia. Key signs are increased blood pressure and protein in the urine (proteinuria). Other symptoms that seem to occur with preeclampsia include persistent headaches, blurred vision or sensitivity to light, and abdominal pain.

Pre-eclampsia

Risk factors for pre-eclampsia include obesity, prior hypertension, older age, and diabetes mellitus. It is also more frequent in a woman's first pregnancy and if she is carrying twins. The underlying mechanism involves abnormal formation of blood vessels in the placenta amongst other factors. Most cases are diagnosed before delivery. Commonly, pre-eclampsia continues into the period after delivery, then known as postpartum pre-eclampsia. Rarely, pre-eclampsia may begin in the period after delivery. While historically both high blood pressure and protein in the urine were required to make the diagnosis, some definitions also include those with hypertension and any associated organ dysfunction. Blood pressure is defined as high when it is greater than 140 mmHg systolic or 90 mmHg diastolic at two separate times, more than four hours apart in a woman after twenty weeks of pregnancy. Pre-eclampsia is routinely screened for during prenatal care.

Hypertensive disease of pregnancy

All of these sensations can be caused by other disorders; they can also occur in healthy pregnancies. Regular visits are scheduled to track blood pressure and level of protein in urine, to order and analyze blood tests that detect signs of preeclampsia, and to monitor fetal development more closely. Classification A classification of hypertensive disorders of pregnancy uses 4 categories as recommended by the U.S. National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy: Chronic hypertension; Preeclampsia-eclampsia; Preeclampsia superimposed on chronic hypertension; Gestational hypertension (transient hypertension of pregnancy or chronic hypertension identified in the latter half of pregnancy).

Hypertension in pregnancy: maternal and fetal outcomes according to laboratory and clinical features.

To determine the predictive value of clinical and laboratory parameters for maternal and fetal complications in pregnant women with hypertension. Prospective data collection. Two primary referral hospitals in the southern suburbs of Sydney between March 1987 and July 1994. 1183 pregnant women with hypertension managed conjointly by a physician and obstetrician. Uniform management protocol, plus antihypertensive medications if systolic blood pressure was persistently > or = 160 mmHg and/or diastolic blood pressure > or = 90 mmHg. Maternal and fetal complications, as defined by the Australasian Society for the Study of Hypertension in Pregnancy Consensus Statement. Of 825 women with pre-eclampsia (502 mild; 323 severe), univariate analysis showed that hyperuricaemia, proteinuria and severe hypertension were significantly associated with a higher rate of maternal and fetal complications. In multivariate analyses without confounders, only primiparity, low serum albumin levels and absence of diabetes were significantly associated with severe pre-eclampsia. Severe pre-eclampsia, high haemoglobin levels and low platelet count were associated with higher rates of small-for-gestational-age babies, but only low serum albumin levels were associated with increased perinatal mortality rates. Low birthweight was associated with severe hypertension and severe pre-eclampsia. Simple clinical and laboratory parameters are useful predictors for maternal and fetal outcomes in pregnancies complicated by hypertension.

Pre-eclampsia

Pre-eclampsia is a progressive disorder and these signs of organ dysfunction are indicative of severe pre-eclampsia. A systolic blood pressure ≥160 or diastolic blood pressure ≥110 and/or proteinuria >5g in a 24-hour period is also indicative of severe pre-eclampsia. Clinically, individuals with severe pre-eclampsia may also present epigastric/right upper quadrant abdominal pain, headaches, and vomiting. Severe pre-eclampsia is a significant risk factor for intrauterine fetal death. A rise in baseline blood pressure (BP) of 30 mmHg systolic or 15 mmHg diastolic, while not meeting the absolute criteria of 140/90, is important to note but is not considered diagnostic.

Hypertensive disease of pregnancy

The diagnostic criteria for chronic hypertension are typically considered to be at least two separate blood pressure readings taken at least four hours apart with systolic blood pressure ≥ 140mmHg, diastolic blood pressure ≥90 mmHg, or both, identified before pregnancy, before 20 weeks gestation, or persisting at least 12 weeks after giving birth. However, there is some controversy over the utility of adopting lower thresholds for diagnosis of chronic hypertension, which is more consistent with recent recommendations from the American College of Cardiology and the American Heart Association for the diagnosis of hypertension in adults. Chronic hypertension in pregnancy is now considered mild if blood pressures do not exceed 159 mmHg systolic and 109 mmHg diastolic and severe if pressures are ≥ 160 mmHg systolic or 110 mmHg diastolic, although controversy also exists as to the most appropriate cutoffs for this definition.

Hypertension In Pregnancy -- Evaluation

The criteria for pre-eclampsia can also be met in the absence of proteinuria if one has new-onset hypertension with thrombocytopenia(platelets less than 100,000 x10(9)/L, renal insufficiency(double of baseline serum creatine or serum creatine >1.1mg/dL), pulmonary edema, impaired liver function (AST/ALT greater than twice upper limit of normal), or new-onset headache unresponsive to medications with no alternative cause.Pre-eclampsia can be superimposed with chronic hypertension, or as advancement along the spectrum of gestational hypertensive disease. Per ACOG guidelines, systolic blood pressure of greater than 160mmHg or diastolic blood pressure greater than 110mmHg on two separate readings 4 hours apart or any severe range pressure that requires antihypertensive medication which by treatment guidelines is severe pressures seperated by minutes(10-30 minutes). [15]

Hypertensive disease of pregnancy

Gestational hypertension Gestational hypertension is a provisional diagnosis that involves newly increased blood pressure in a pregnant woman that usually develops after 20 weeks of gestation, but does not currently show any signs of proteinuria or other features associated with preeclampsia. Up to 50% of gestational hypertension patients go on to develop some form of preeclampsia. Gestational hypertension will normally resolve by 12 weeks postpartum. In this case, the diagnosis of gestational hypertension will be updated to be transient hypertension of pregnancy. If the increased blood pressure does not resolve by 12 weeks postpartum, then the diagnosis of gestational hypertension will be updated to be chronic hypertension.

Hypertension

Pregnancy Hypertension occurs in approximately 8–10% of pregnancies. Two blood pressure measurements six hours apart of greater than 140/90 mm Hg are diagnostic of hypertension in pregnancy. High blood pressure in pregnancy can be classified as pre-existing hypertension, gestational hypertension, or pre-eclampsia.

Hypertensive disease of pregnancy

There is limited evidence to suggest that calcium supplementation may reduce the risk of pre-eclampsia or stillbirth but it is unclear if it has other benefits. Prognosis The effects of high blood pressure during pregnancy vary depending on the disorder and other factors. Preeclampsia does not in general increase a woman's risk for developing chronic hypertension or other heart-related problems. Women with normal blood pressure who develop preeclampsia after the 20th week of their first pregnancy, short-term complications, including increased blood pressure, usually go away within about six weeks after delivery. Some women, however, may be more likely to develop high blood pressure or other heart disease later in life. More research is needed to determine the long-term health effects of hypertensive disorders in pregnancy and to develop better methods for identifying, diagnosing, and treating women at risk for these conditions.

Pre-eclampsia

Differential diagnosis Pre-eclampsia can mimic and be confused with many other diseases, including chronic hypertension, chronic renal disease, primary seizure disorders, gallbladder and pancreatic disease, immune or thrombotic thrombocytopenic purpura, antiphospholipid syndrome and hemolytic-uremic syndrome. It must be considered a possibility in any pregnant woman beyond 20 weeks of gestation. It is particularly difficult to diagnose when pre-existing conditions such as hypertension are present. Women with acute fatty liver of pregnancy may also present with elevated blood pressure and protein in the urine, but differ by the extent of liver damage. Other disorders that can cause high blood pressure include thyrotoxicosis, pheochromocytoma, and drug misuse.

Hemodynamic measurements with Swan-Ganz catheter in women with severe proteinuric gestational hypertension (pre-eclampsia).

Ten women with severe pre-eclampsia, i.e. a blood pressure greater than or equal to 150/110 mmHg or 140/90 mmHg and proteinuria greater than 3 g/24 h were, after initial antihypertensive treatment, centrally monitored with a pulmonary artery catheter (Swan-Ganz). All had been normotensive in early pregnancy. Mean age was 29 years (range 23-37). Mean gestational age upon admission was 29 weeks (range 23-36) and 7 of the women were nulliparous. Nine of the 10 patients had subjective symptoms, e.g. headache and/or epigastric pain. All were considered in need of intensive care. Two patients were found to have an abnormal coagulation and liver function. All patients had normal serum creatinine values despite proteinuria. Hypertension was treated with dihydralazine and/or labetalol. Volume substitution was carried out with plasma and albumin. The women could be divided into two groups: 5 patients where progress of the disease despite therapy led to delivery within 24 h, and 5 patients whose diastolic blood pressure could be stabilized around 100 mmHg after treatment and pregnancy could be prolonged by 5-13 days. Common for all patients was a hyperkinetic circulation with an increased cardiac output despite a variety of central pressures. Invasive monitoring of central pressures with a Swan-Ganz catheter demonstrated that the clinical status could be stabilized and the pregnancy prolonged in 5 of the 10 women with severe pre-eclampsia. The variety of the central hemodynamic values illustrates clearly that treatment has to be individualized regarding antihypertensive medication, fluids and diuretics.(ABSTRACT TRUNCATED AT 250 WORDS)

Maternal mortality in the United States

Pre-eclampsia: at about 20 weeks until after delivery, pregnant women can have an increase in blood pressure which could indicate pre-eclampsia. Pre-eclampsia involves the liver and kidneys not working properly which is indicated by protein in the urine as well as having hypertension. Pre-eclampsia can also become eclampsia, the mother seizes or is in a coma, which is rare but fatal. Due to this risk, blood pressure is closely monitored at every routine obstetric visit, and patients with increased blood pressure may be referred to a high-risk specialist.

Hypertensive disease of pregnancy

Preeclampsia can also present with seizures in the pregnant mother. In this case, the patient would be diagnosed with eclampsia. There is no proven way to prevent preeclampsia/eclampsia. Most women who develop signs of preeclampsia, however, are closely monitored to lessen or avoid related problems. The only way to "cure" preeclampsia/eclampsia is to deliver or abort the baby. Eclampsia Eclampsia is one particularly concerning form of preeclampsia in which a pregnant woman who previously presented with signs of newly increased blood pressure begins to experience new generalized seizures or coma. Up to 70% of patients with eclampsia experience complications associated with pregnancy. These complications can include HELLP syndrome, acute kidney injury, and disseminated intravascular coagulation among others.

Hypertensive encephalopathy

Hypertensive encephalopathy (HE) is general brain dysfunction due to significantly high blood pressure. Symptoms may include headache, vomiting, trouble with balance, and confusion. Onset is generally sudden. Complications can include seizures, posterior reversible encephalopathy syndrome, and bleeding in the back of the eye. In hypertensive encephalopathy, generally the blood pressure is greater than 200/130 mmHg. Occasionally it can occur at a BP as low as 160/100 mmHg. This can occur in kidney failure, those who rapidly stop blood pressure medication, pheochromocytoma, and people on a monoamine oxidase inhibitor (MAOI) who eat foods with tyramine. When it occurs in pregnancy it is known as eclampsia. The diagnosis requires ruling out other possible causes.

Hypertension

Pre-eclampsia is a serious condition of the second half of pregnancy and following delivery characterised by increased blood pressure and the presence of protein in the urine. It occurs in about 5% of pregnancies and is responsible for approximately 16% of all maternal deaths globally. Pre-eclampsia also doubles the risk of death of the baby around the time of birth. Usually there are no symptoms in pre-eclampsia and it is detected by routine screening. When symptoms of pre-eclampsia occur the most common are headache, visual disturbance (often "flashing lights"), vomiting, pain over the stomach, and swelling. Pre-eclampsia can occasionally progress to a life-threatening condition called eclampsia, which is a hypertensive emergency and has several serious complications including vision loss, brain swelling, seizures, kidney failure, pulmonary edema, and disseminated intravascular coagulation (a blood clotting disorder).

Outline of cardiology

Complications of hypertension Hypertrophic cardiomyopathy – Increased pressure results in hypertrophy of the myocardium, particularly left ventricular hypertrophy. Pulmonary hypertension — which is separate from "hypertension" described above — can result in right ventricular hypertrophy. Hypertensive crisis – Generally considered to be a systolic blood pressure over 180. If there is no organ dysfunction it is called a hypertensive urgency, but if there is (e.g., confusion, breathlessness) then it is called hypertensive emergency. Pre-eclampsia (PreE) / Eclampsia – PreE is a disease of pregnancy that results in hypertension and proteinuria. PreE has negative consequences for both the mother and fetus/baby. Progression to eclampsia involves seizures. Currently, the only definitive treatment is delivery of the fetus. Hemorrhagic stroke – Infarction of the brain due to internal bleeding from Charcot–Bouchard aneurysms.

Pre-eclampsia

The goal of treatment of severe hypertension in pregnancy is to prevent cardiovascular, kidney, and cerebrovascular complications. The target blood pressure has been proposed to be 140–160 mmHg systolic and 90–105 mmHg diastolic, although values are variable. Prevention of eclampsia The intrapartum and postpartum administration of magnesium sulfate is recommended in severe pre-eclampsia for the prevention of eclampsia. Further, magnesium sulfate is recommended for the treatment of eclampsia over other anticonvulsants. Magnesium sulfate acts by interacting with NMDA receptors. Epidemiology Pre-eclampsia affects approximately 2–8% of all pregnancies worldwide. The incidence of pre-eclampsia has risen in the U.S. since the 1990s, possibly as a result of increased prevalence of predisposing disorders, such as chronic hypertension, diabetes, and obesity.