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1/37. Spontaneous lung herniation after a single cough.

    Herniation of the lung is commonly caused by congenital rib abnormalities, blunt trauma, or thoracic surgery. Spontaneous hernias are rarely described in the literature. We report a case of a spontaneous intercostal pulmonary hernia following a single cough. In addition, a review of the literature is presented which outlines the classification, causes, and incidence of lung hernias. Some reference is made to possible methods of treatment.
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2/37. Hyperacute infarction: early CT findings.

    The aim of our study is to determine how early and reliably ischemic brain infarcts can be detected on CT scanning. We report two cases of an early CT finding of acute ischemic infarcts where CT examination was obtained within the first 3 hours of onset of neurological symptoms. CT examination showed blurred outlines and decreased attenuation of the left lentiform nucleus, loss of the white-gray matter interface in the left insular cortex and left cortical global hypoattenuation with obliteration of left cortical sulci in one patient. In second patient CT showed the following: hyperdense left middle cerebral artery, loss of clear margins of left lentiform nucleus, subtle focal cortical hypodensity in the left fronto-parietal area with signs of mass effect in the form of ventricular compression. CT is still the first choice in the deferential diagnosis of acute stroke. Although older literature positions have suggested that CT was negative during the first 48 hours, modern CT technology can demonstrate positive findings even in the first 3 hours of onset. This is important in patients with acute stroke, as thrombolytic therapy when elected, has to be given within the first 3-6 hours after onset of symptoms. To determine how early and reliably ischemic brain infarcts can be detected on CT scanning, we report two cases of an early CT finding of acute ischemic infarcts where CT examination was obtained within the first 3 hours of onset of neurological symptoms.
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3/37. Acute asthma. Emergency management in the community.

    BACKGROUND: The prevalence of asthma in australia is one of the highest in the world. statistics suggest that two million or more Australians across all age groups have the disease. It is one of the top five medical problems referred to hospital and one of the commonest presentations seen in emergency departments. asthma was the cause of death of 685 Australians in 1998. All general practitioners will have a cohort of asthmatics in their practice and consequently must be prepared to manage these people at any time, but especially at times of acute exacerbation. OBJECTIVE: To outline the features of acute asthma and its management in the community setting. DISCUSSION: general practitioners have a crucial role to play in the community and prehospital management of asthma. An awareness of the features and treatment of acute exacerbations will help them reduce an enormous burden on the health system and contribute to a reduction in morbidity and mortality in their patients.
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4/37. Viral hepatitis? Which test should I order?

    BACKGROUND: There are a multitude of viruses that may cause hepatitis. The laboratory diagnosis of viral hepatitis is important in order to plan immediate patient management, determine treatment choices and provide patient education in order to limit transmission of infections to others. OBJECTIVE: This article outlines laboratory investigations that may be routinely ordered to assist in determining the etiology of viral hepatitis and summarises some preventive and treatment strategies that may be adopted. DISCUSSION: Investigations to determine exposure to infection are routinely performed and include simple serological tests, while tests to follow the course of infection or response to treatment may involve newer molecular techniques, including polymerase chain reaction (PCR), genotyping and viral quantification.
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5/37. Acute pleuritic chest pain.

    BACKGROUND: The differential diagnosis of acute pleuritic chest pain is large and includes a number of life threatening conditions. Clinical suspicion plays a major role in the choice of investigation and the interpretation of the results. OBJECTIVE: To outline the clinical features and diagnostic workup of three acute causes of pleuritic chest pain--acute pulmonary embolism, pneumothorax and acute pericarditis. DISCUSSION: The general practitioner plays an important role in the initiation of the investigative pathway for these conditions. Appropriate referral for ongoing assessment and care requires the primary care physician to be aware of the available investigations and their limitations.
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6/37. Acute autoimmune cardiomyopathy in primary antiphospholipid antibody syndrome.

    We present a case of acute pulmonary oedema as the first presentation of autoimmune cardiomyopathy in primary antiphospholipid antibody syndrome in a patient who had no previous cardiac history. Five days of methylprednisolone at 500 mg/day followed by 100 mg/day for 10 days and then a weaning course of oral prednisone resulted in effective resolution of the acute diffuse cardiomyopathy. Her cardiac status became clinically and echocardiographically normal. We illustrate the effectiveness of immunosuppressive therapy as an adjunct to standard anti-failure measures in such presentations and we outline the association between antiphospholipid antibodies and cardiac dysfunction.
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7/37. Bone loss and recovery in regional migratory osteoporosis.

    Regional migratory osteoporosis (RMO) is a migrating arthralgia of the weight-bearing joints of the lower limb associated with focal osteoporosis. Little information is available on a quantitative assessment of systemic or local osteoporosis. In this study, we report three cases of RMO in which spine, hip and whole body serial assessments of bone mass have been evaluated to outline their extent and time course of changes. Systemic osteoporosis, with a prevalent involvement of the mainly trabecular skeletal sites, was present in all the patients, with T-scores below -2.5 at both the lumbar spine and femoral neck. Bone loss in acute episodes ranged from -75.5% to -14.7% and appeared related to the severity of the episode. In acute episodes the demineralizing process affected the whole limb from the hemipelvis to the foot: the bone loss ranged from -33.6% to -3.5% at sites with prevalent trabecular composition and from -19.1% to -1.1% at sites with prevalent cortical composition. Bone recovery was complete in one episode out of six. In the other five cases, the average residual bone loss was 26% (range 13.9-32.7%). Our observations suggest that RMO occurs in subjects with systemic osteoporosis and densitometric assessment may aid in the clinical management.
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8/37. Acute infectious purpura fulminans: a 15-year retrospective review of 28 consecutive cases.

    Acute infectious purpura fulminans (AIPF) is a rare syndrome of hemorrhagic infarction of the skin, extremity loss, and intravascular thrombosis. It progresses rapidly and is accompanied by disseminated intravascular coagulation and vascular collapse. The victims often succumb to the disease. Our objective was to investigate the clinical manifestations, outline the clinical course, and delineate factors related to mortality among the patients with AIPF. patients diagnosed with AIPF over a 15-year period were reviewed retrospectively for patient history, comorbid conditions, progression of clinical course, and medical and surgical management. The vast majority of the patients were under the age of 7; however, the disease process can be seen in adults. The overall mortality rate was 43 per cent. The major predisposing factors were history of recent upper respiratory infection, recent surgery or childbirth, young age, and absence of a spleen. The most common clinical manifestations were skin discoloration, disseminated intravascular coagulation, fever, and septic shock. The most common bacteria cultures were neisseria meningitidis, Hemophilus influenzae, and streptococcus pneumoniae. There appears to be a higher mortality in patients who did not undergo a surgical intervention. Compartment syndrome needs to be evaluated early on in the presentation. Rapid diagnosis, intensive care unit management, and prompt surgical consultation and debridement may decrease the mortality.
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9/37. Nontraumatic acute complete paraplegia resulting from cervical disc herniation: a case report.

    STUDY DESIGN: A case report of nontraumatic acute complete paraplegia resulting from cervical disc herniation. OBJECTIVES: To describe a rare case of nontraumatic paraplegia resulting from enlargement of a herniated disc in the cervical spine and to outline appropriate management of a patient with severe spinal cord compression secondary to disc herniation with developmental spinal canal stenosis. SUMMARY OF BACKGROUND DATA: Acute progression of myelopathy into complete paraplegia resulting from disc herniation is rare. There are only four reported cases of nontraumatic acute myelopathy secondary to cervical disc herniation. No other report has described magnetic resonance imaging findings noted before and after the onset of acute myelopathy. methods: A cervical disc herniation at C6-C7 is reported in a 29-year-old man who had nontraumatic acute complete paraplegia. Neurologic and magnetic resonance imaging findings are evaluated and discussed.RESULTS: Disc herniation at C6-C7 enlarged nontraumatically, resulting in complete paraplegia. Emergent anterior decompression followed by secondary posterior multilevel decompression was performed. magnetic resonance imaging studies revealed localized high signal intensity change in the spinal cord. No neurologic recovery was achieved 3 years post-surgery. CONCLUSION: We emphasize that there is a possibility of acute, irreversible progression of paralysis secondary to nontraumatic enlargement of cervical disc herniation with canal stenosis. In these cases, immediate early decompressive surgery is crucial to the prevention of severe myelopathy.
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10/37. Acute disseminated encephalomyelitis: a riddle wrapped in a mystery inside an enigma.

    The difficulties in establishing a diagnosis of acute disseminated encephalomyelitis (ADEM) are illustrated in this case report, which attempts to raise awareness of the condition among general physicians, since they are the practitioners most likely to see such acute neurological presentations. Clinical and investigative features which raise the index of suspicion for the diagnosis of ADEM are outlined.
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