Presenting Symptoms of MS

(Australia—Australian Family Physician, September 1999, p. 903.) Multiple sclerosis (MS) is a common chronic neurologic disease that can present with almost any neurologic symptom. Approximately 40 percent of patients initially experience limb weakness. The weakness may involve one or more limbs, be symmetrical or asymmetrical, and present suddenly or evolve over time. Accompanying sensory and sphincteric symptoms are also common. A variety of signs may be found on neurologic examination. About one fourth of cases of MS present as optic neuritis, usually with decreasing visual acuity and pain that increases with eye movement. Forty-six percent of patients with optic neuritis develop neurologic symptoms over 13 years of follow-up. Diplopia is also a common presentation of MS, occurring in approximately 12 percent of new patients. Although less common, internuclear ophthalmoplegia is strongly suggestive of MS. Disturbances of sensation are reported to be the initial symptoms in 21 percent of patients with MS. One form of sensory disturbance is the “useless hand” syndrome resulting from loss of position sense in one or both hands. Although not pathognomonic for MS, Lhermitte's sign (an electric-like sensation in the back of the legs on flexing the neck) is highly suggestive of the diagnosis.

New Treatments in Unstable Angina

(Great Britain—The Practitioner, October 1999, p. 706.) Disruption of an atheromatous plaque in a coronary artery provokes a series of responses leading to the formation of a platelet-rich thrombus. While small thrombi may lyse spontaneously or become incorporated into a plaque, larger thrombi tend to cause clinical symptoms, including unstable angina. Despite optimal medical management, approximately 10 percent of patients with unstable angina die or suffer myocardial infarction within six months of onset. Currently, the nonspecific inflammatory marker C-reactive protein may be the only available laboratory indicator of increased risk of cardiac events. More sensitive markers of myocardial damage based on myocardial structural proteins (troponins) are being developed to identify the subgroup of patients with unstable angina who are at greatest risk of cardiac events. Several new treatments are being developed to ameliorate unstable angina. Statin drugs, initially developed to lower serum cholesterol levels, are now believed to help prevent unstable angina by stabilizing plaques. Because Chlamydia pneumoniae may be involved in plaque formation or disruption, antibiotic therapy is being assessed. Finally, a number of new antithrombotic drugs are in development to provide more effective treatment than traditional aspirin or heparin therapies.

Primary Care for the MI Survivor

(Great Britain—The Practitioner, October 1999, p. 728.) Patients who survive myocardial infarction (MI) are at high risk of further cardiac events. Rehabilitation aims to minimize this risk and return patients to a normal, active life. In addition to medical and psychologic support, patients generally have concerns about symptom control, driving, sexuality, employment, exercise and lifestyle issues. Symptoms such as palpitations, breathlessness or chest pain could indicate a deterioration in the patient's cardiac condition and should be promptly investigated and treated. Decisions about employment and driving must be individualized and frequently require exercise testing or other investigations to verify fitness to return to previous activities. The tachycardia associated with sexual activity is about 130 beats per minute, which is roughly equivalent to walking a mile in 17 minutes, or ascending and descending 12 stairs; patients are often advised that it is safe to resume sexual activity when this level of exercise can be accomplished. All patients should be counseled to stop smoking; achieve optimal body weight, blood pressure and blood lipid levels; and maintain regular exercise. Control of blood sugar is essential for diabetic patients. The benefit of hormone replacement therapy in women following myocardial infarction is unclear.

Discoid Eczema

(Australia—Australian Family Physician, October 1999, p. 1021.) Discoid or nummular eczema presents as thin, “coin-shaped” erythematous plaques that often have a scaly center. The lesions may be pruritic and are exacerbated by dryness and heat. If central clearing occurs, discoid eczema can resemble tinea infection. Microscopic examination of skin scrapings may establish the diagnosis. The scaling of discoid eczema may also cause confusion with psoriasis. Psoriatic lesions usually have thicker scales that appear silvery after rubbing and bleed on removal. The distribution of psoriasis on extensor surfaces, scalp and natal cleft helps distinguish psoriasis from discoid eczema. Patients with discoid eczema should avoid using soap and taking hot showers. Lesions can be treated with local application of an emollient and topical corticosteroid.