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Benign intracranial hypertension is known to be associated with obesity, endocrine abnormalities, various medications, and cerebral venous sinus thrombosis. We report a patient presenting with headaches and vomiting attributed to benign intracranial hypertension. The diagnostic work-up revealed Langerhans' cell histiocytosis of the occipital bone. There was no evidence for cerebral vein thrombosis by cranial computed tomography scan, Doppler ultrasonography, planar and single photon emission computed tomography technetium 99m-labelled red blood cell scintigraphy, and magnetic resonance angiography. Excision of the occipital bone lesion and a short course of acetazolamide and prednisone were curative. We hypothesize that cytokines secreted by the tumor were responsible for the development of intracranial hypertension.
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PMID:Langerhans' cell histiocytosis presenting as intracranial hypertension. 1141 6

Hepatitis B and its sequelae are a major public health problem. Vaccines have been available for almost 20 years; however the disease still remains a global problem. Many factors contribute to the failure to control hepatitis B, including the limited nature of the vaccination programs implemented initially. Only relatively recently has mass childhood vaccination begun to be implemented and vaccination of high-risk groups, other than healthcare workers, is still not general policy. Additional factors contributing to continued persistence of hepatitis B in the developed world are that the present vaccines are not fully used by those recommended to be vaccinated and even when vaccination is carried out appropriately, there remain some who fail to achieve adequate protection. Clearly, the protection of at-risk groups who have inadequate response to current vaccines, and those who are unwilling or unable to comply with protracted multi-dose vaccine regimens, could be improved if there were a more potent vaccine and/or a shorter vaccination regimen available. Adults who had never been vaccinated against hepatitis B were randomised to receive a vaccination course of either a present single antigen (S) vaccine (Recombivax-HB) or a novel triple antigen (S, pre-S1, and pre-S2) recombinant vaccine (Hepacare Medeva Pharma plc). Doses were given at baseline and 1 month and 6 months later. Hepatitis B surface antibody (anti-HBs) levels were measured at 2, 4, 6, and 7 months after beginning vaccination. The primary efficacy parameter was the degree of protection, measured as the percentage of subjects with anti-HBs titres > or = 10 IU/L, 6 or 7 months (26 +/- 2 weeks) after beginning vaccination. A total of 303 adult subjects entered the study and were vaccinated. Of these, 11 failed to complete the study (4 on Hepacare and 7 on Recombivax-HB); however all but 2 (1 to receive the triple antigen vaccine and 1 to receive Recombivax-HB) were included in the intent-to-treat population for efficacy evaluation. Treatment randomisation was stratified at entry based on age (above and below 40 years old) and gender. The standard three-dose/6-month vaccination regimen of the single antigen vaccine protected 83% of subjects by 7 months after starting vaccination whereas the triple antigen vaccine as a two-dose/1-month regimen protected 88% within 6 months and as a three-dose/6-month regimen protected 97% by 7 months after starting vaccination. Thus the protection rate provided by the shortened (0, 1) regimen of the novel vaccine was "essentially equivalent" (i.e., not statistically inferior) to that provided by the full (0, 1, and 6) regimen of today's vaccine (88% vs. 81%, P < 0.001), and the protection rate provided by a three-dose/6-month (0, 1, and 6) regimen of the new vaccine was significantly superior to that provided by present vaccines (97% vs. 83% P < 0.001). The percentage of subjects protected increases with time after beginning vaccination and at all time points up to and including 6 months was significantly greater with the two-dose regimen of the triple antigen vaccine than with the single antigen vaccine regimen. In adults at risk for a reduced response to hepatitis B vaccination [i.e., older adults (>/=40), the obese, males, and smokers], the triple antigen vaccine produced a significantly greater percentage of protected subjects (P < 0.001) and higher geometric mean titre (P < 0.001). Indeed as a three-dose/6 month regimen, the triple antigen vaccine raised the level of protection in these vulnerable subgroups to that seen when a single antigen vaccine is used in the optimal younger adult group. Both vaccines were well tolerated and had similar safety profiles. The most frequently (> or = 10%) reported adverse events with the use of either vaccine were pain at the site of injection (38% vs. 41% vs. 20% for the two-dose Hepacare regimen, the three-dose Hepacare regimen, and the three-dose Recombivax-HB regimen, respectively), infections at the site of injection (1% vs. 14% vs. 9%), headache (9% vs. 13% vs. 11%), and nausea (7% vs. 11% vs. 3%). It is concluded that in healthy normal adults, a triple antigen hepatitis B vaccine that contained S and pre-S antigens produced an enhanced immunological response. This was exemplified by the novel vaccine's ability to overcome factors such as advancing age (> or = 40 years), obesity, and smoking, each of which is known to reduce the potential for protection with present recombinant S only vaccines. A two-dose/1-month (0 and 1) regimen of this triple antigen vaccine was as effective as the standard three-dose/6 month (0, 1, and 6) regimen of present single antigen vaccines. (c) 2001 Wiley-Liss, Inc.
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PMID:Comparison of a triple antigen and a single antigen recombinant vaccine for adult hepatitis B vaccination. 1142 17

1. Forty percent of transplant centers expect the primary care physician to be the primary physician; 40% have both a primary care physician and a hepatologist manage the patient. 2. Transplant centers expect primary care physicians to provide general preventive medicine, physical examinations, vaccinations, and, rarely, management of hypertension, renal dysfunction, and diabetes. 3. A high percentage of primary care physicians feel comfortable caring and managing the overall health care of a long-term liver transplant patient. 4. Primary care physicians feel at most ease managing preventive care, annual physical examinations, hypertension, diabetes mellitus, hyperlipidemia, bone disease, and vaccinations. 5. Primary care physicians should be aware of the common medical conditions of the liver transplant patient of hypertension, diabetes, obesity, hyperlipidemia, and recurrent disease. 6. Common medical conditions for both the transplant centers and primary care physicians are hypertension, dyslipidemia, diabetes mellitus, malignancy, bone disease, pregnancy, vaccination, infectious prophylaxis, and headaches.
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PMID:Posttransplantation care: role of the primary care physician versus transplant center. 1168 71

Several scores exist to clinically differentiate between ischemic and hemorrhagic stroke, but none has been developed in the emergency situation in which transient ischemic attack (TIA) and cerebral infarction might not yet be clearly distinguished. Information on 540 patients with ischemia (including TIA) or hemorrhage was abstracted from medical charts. Of 540 patients hospitalized with stroke, 98 had a hemorrhage. Age, obesity, anamnestic stroke/TIA, peripheral arterial disease, onset during physical activity, headache, impaired consciousness, hemisyndrome, meningismus and systolic blood pressure contributed to the differential diagnosis and were included in our proposed score. The score performed well in comparison with existing scores. The inclusion of TIA and the explicit incorporation of incomplete information may enhance the applicability of differential diagnostic scores in the prehospital emergency situation.
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PMID:Clinical diagnosis of ischemic versus hemorrhagic stroke: applicability of existing scores in the emergency situation and proposal of a new score. 1174 20

Pseudotumor cerebri is a condition of intracranial hypertension without localizing signs except for papilledema with normal intracranial contents and normal cerebrospinal fluid constituents. It is seen more frequently in women than in men (8:1) especially women are of childbearing age, and in 90% of cases of obesity. The most common symptoms are headache and visual obscuration. Other symptoms include pulsatile tinnitus, shoulder and arm pain. The papilledema present in almost all PTC patients can lead to decreased vision and blindness. One third of the large series had substantial visual loss including loss of visual field. Treatment has been directed toward preserving vision. Medications that reduce intracranial pressure such as diuretics like Acetazolamide have some success. When vision is threatened, these individuals may undergo optic nerve sheath decompression or lumbar peritoneal shunt to preserve vision. Even with prompt intervention, visual loss can occur.
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PMID:[Pseudotumor cerebri (PTC--an update)]. 1194 27

Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri, can be a serious vision-threatening disease. Visual acuity, visual fields, and ocular fundus appearance should be followed closely in all patients with IIH. Obese patients with IIH should be encouraged to lose weight. Medications that might cause or exacerbate IIH should be identified and discontinued if possible. Mild headaches can be treated with nonsteroidal anti-inflammatory drugs (NSAIDs) or migraine prophylactic agents. Some patients may not require additional treatment if they are otherwise asymptomatic and have no evidence of vision loss. Symptomatic patients (significant headache, visual complaints, tinnitus) or patients with visual field or acuity loss should be treated initially with acetazolamide. Furosemide may be a useful second-line agent. If vision loss is progressive despite maximal medical therapy or severe at the time of diagnosis, surgical intervention may be required. Optic nerve sheath fenestration is effective and safe, and may be repeated if initially unsuccessful. Lumboperitoneal shunting is also an option, especially if symptoms of headache are prominent and refractory to medical therapy, but it has significant complication and failure rates. Bariatric surgery can be an effective treatment for IIH in severely obese patients, but is not a useful acute intervention. Special issues must be considered when treating IIH in children or pregnant women.
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PMID:Idiopathic Intracranial Hypertension. 1203 3

This article is a long list of the known side effects of OC (oral contraception). Less serious side effects include skin alterations, genito-urinary infections, anemia, headaches, psychological problems of various kinds, cholestasis and/or jaundice, menstruation disorders, and metabolic perturbations. Very serious side effects include all cardiovascular, cerebrovascular and blood coagulation problems; carcinogenic effects are to be included among serious ones, even if not totally proven. Factors increasing the risk of severe disorders are tabagism, obesity, age, hypertension, and family antecedents of thrombotic accidents. Sex hormones are suspected to induce malformation in the fetus. OC must be carefully chosen according to the clinical and biological characteristics of the users; the lowest dosage is always recommended when effectiveness is equal.
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PMID:[Pharmacological aspects of oral contraceptives: part 2 (author's transl)]. 1226 34

Included in this article is a table adapted from World Health Organization medical eligibility guidelines developed to assist practitioners in the prescription of low-dose oral contraceptives (OCs). These guidelines are part of a broader project aimed at improving access to all available methods of contraception without creating unacceptable risk. They were formulated in response to concerns that current practices are based on scientific studies of contraceptive products that are no longer in wide use, the bias of service providers, and a tendency to render relative contraindications absolute. If the presence of a condition creates no obstacle to method use, a Category I rating is assigned. If the benefits of a method generally outweigh the risks, the condition receives a Category 2 rating. Category 3 applies to conditions carrying risks that generally outweigh benefits, while Category 4 applies to conditions carrying unacceptable health risks. Health conditions categorized in association with low-dose OC use are post-abortion, diabetes, superficial venous thrombosis, known hyperlipidemias, headaches, vaginal bleeding patterns, unexplained vaginal bleeding, breast disease, pelvic inflammatory disease, sexually transmitted diseases, HIV/AIDS, viral hepatitis, uterine fibroids, past ectopic pregnancy, obesity, thyroid disorders, trophoblast disease, and sickle cell disease.
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PMID:Increasing access to combination oral contraceptives. 1229 65

The main concern of physicians prescribing oral contraceptives (OCs) is the possibility of cardiovascular accidents, not because of their number but of their seriousness. Cardiovascular risk affects primarily women over 35. A 1986 survey of 600 physicians indicated that avoiding cardiovascular risk was their main objective when prescribing pills, with avoidance of modifications in lipid and glucose metabolism virtually as great a concern. Less than 50% were concerned with functional symptoms such as spotting which can be managed by therapeutic adjustments. Numerous cofactors participate in cardiovascular risk, including family history, life style, and intercurrent illness. The frequency of vascular accidents is only slightly higher among OC users than in the control population. Numerous Anglo-Saxon studies have found the risk of deep venous thrombosis to be multiplied by 4 or 5 for OC users and of superficial thrombosis to be multiplied by 2 or 3. Age and obesity play no role in the increased risk for OC users, smoking has a minor role, and family history and bed rest are the only major cofactors. Risk of venous thrombosis under OC use does not depend on duration of use and disappears the month after termination of use. The synthetic estrogen is primarily responsible because of the modifications it produces on coagulation factors. OC use increases the risk of coronary accidents by 3 or 4. 3 hypotheses have been advanced to explain the pathogenic mechanism: classic atherogenesis, alteration of the intima, or immunological factors. Atheromatous arterial accidents are related to age, smoking, problems of glucose or lipid metabolism, and blood pressure. The factors have a synergistic effect on each other. Risks increase with duration of use and dose level, and depend also on the biochemical properties of the estrogen and progestin. Some accidents in young women about 30 years old show no relation to duration of use or dose. The only elements differentiating the women involved are smoking, family histories of vascular accidents, and intense headaches in the days before a cerebrovascular accident. They seem to be associated not with atherogenesis but with thickening of the intima secondary to a proliferation of smooth muscle cells with subendothelial fibrosis. 90% of OC users experiencing vascular accidents have been found to have anti-ethinyl estradiol antibodies, compared to 30% of users never having vascular accidents and no nonusers. The practical import of this finding remains undetermined. Under some circumstances the causes of headaches should be investigated and OC use should be terminated. Careful attention to patient selection and development of new progestins with fewer androgenic and metabolic effects should reduce cardiovascular risks from OCs to a minimum. The new synthetic progestin gestodene has given very satisfactory results in a triphasic formulation and should be on the market soon.
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PMID:[Combined contraceptives and cardiovascular risk]. 1231 99

The added risks of thromboembolic disease in pill users who also smoke cigarets are enumerated, then the physiological mechanisms explained. From retrospective studies it seems that heart attacks are more likely in women with oral contraception, smoking, obesity, hypertension, diabetes, and high cholesterol. With 1 of these factors the risk is 4-fold, with 2 factors 10-fold, and with 3 factors 78-fold, i.e., a synergic not additive effect. The progestagen in the pill is primarily responsible, acting by causing microthrombi. Strokes are more likely when headaches and hypertension, or oral contraception and smoking are present. Smoking is more often associated with hemorrhagic strokes, while hypertension increases risks of thrombotic and hemorrhagic strokes. The following effects of smoking are probably involved in thromboembolic disease: tachycardia, hypertension, peripheral vasoconstriction, carbon monoxide, inhibition of fibrinolysis, atherosclerosis, and increased blood viscosity.
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PMID:[Smoking and oral contraceptives]. 1233 82


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