Diagnosing the cause of vertigo: a practical approach.

Dizziness is among the commonest of chief complaints. It often presents a significant challenge to the attending physician, because the symptoms and signs are often vague and non-specific. However, a robust systematic approach can usually arrive at the diagnosis. Maintaining balance requires sensory inputs from the vestibular, visual, and somatosensory systems and the cerebellum fine-tunes inaccurate motor outputs. Causes of vertigo are most commonly otological, followed by central, somatosensory, and visual. The first question in approaching patients with dizziness is to categorise dizziness into one of the four groups: lightheadedness, pre-syncope, disequilibrium, and vertigo. Secondly, central vertigo has to be differentiated with peripheral vertigo. For peripheral vertigo, the most common cause is benign paroxysmal positional vertigo and should be specifically looked for. The tempo of the vertiginous attacks and other associated symptoms can help differentiate the other causes of peripheral vertigo, including Meniere's disease, vestibular neuronitis, labyrinthitis, and a perilymph fistula.

Alveolar capillary dysplasia with congenital misalignment of pulmonary vessels.

Alveolar capillary dysplasia with misalignment of pulmonary vessels is an uncommon congenital cause of persistent pulmonary hypertension of the newborn. It is universally fatal, and diagnosis is entirely dependent upon surgical lung biopsy. We present a case of alveolar capillary dysplasia with misalignment of pulmonary vessels occurring in a full-term neonate, emphasizing that early involvement of the thoracic surgeon for a histological diagnosis allows expensive and ineffective treatments to be avoided.

Severe acute respiratory syndrome complicated by spontaneous pneumothorax.

Severe acute respiratory syndrome (SARS) presents an unprecedented diagnostic and therapeutic challenge to clinicians. Despite recent progress in identifying and analyzing the coronavirus that is responsible for it, few reports have addressed the clinical complications of SARS. The present study was a two-center retrospective cohort study. All patients in the study had SARS, were managed in the two major Hong Kong hospitals (ie, Prince of Wales Hospital and United Christian Hospital), and had developed spontaneous pneumothorax during their hospitalization between March 10, 2003, and April 28, 2003. Spontaneous pneumothorax was reported in 6 of 356 SARS patients who were treated at the two hospitals during the period. This represents an incidence of 1.7%. None of the six patients had a history of smoking or pulmonary disease. The rate of admission to the ICU was 66.7% and the crude mortality rate was 33.3% in this group of patients. There was a trend for the mean neutrophil count in these patients to be higher than in previously reported cohorts of comparable SARS patients (14.5 x 10(9) vs 4.6 x 10(9) neutrophils per liter, respectively). Conservative measures like tube thoracostomy or observation alone offered satisfactory initial symptomatic management in five of six patients. Spontaneous pneumothorax is a specific and potentially life-threatening complication in SARS patients. Patients with extensive lung injury, as indicated by severe clinical courses, and in particular high neutrophil counts, appear to be most at risk. The benefits of surgical management must be balanced against the potential risks to health-care workers.

Hearing impairment and depressive symptoms in an older chinese population.

OBJECTIVE: To investigate the association of objectively measured hearing loss and depression in an older Chinese population. DESIGN: Cross-sectional study. SETTING: Screening service provided to the elderly as part of a charity program in collaboration with a local group of medical and audiologic professionals. METHODS: A cross-sectional study was conducted on community-dwelling people aged 60 years or above using pure-tone audiometry in a soundproof environment together with a validated Cantonese version of the Geriatric Depression Scale. The association of hearing loss and depression, together with a number of predisposing factors, was examined with multivariate analysis. The effect of hearing aid use was investigated in some subjects. MAIN OUTCOME MEASURES: The effect of both self-reported hearing impairment and objectively measured hearing loss on depressive symptoms, together with a number of predisposing factors, was examined with multivariate analysis. RESULTS: Excluding those suffering from dementia, 914 people were included. Logistic regression showed that the main predicting factors of depression were poor self-perceived health, measured hearing loss, and female gender. Measured hearing loss gave an odds ratio of 1.649 (95% CI 1.048-2.595). The association of self-reported hearing loss with depression was shown in univariate analysis but not in multivariate analysis. Hearing aid use showed a tendency toward reducing depressive symptom scores. CONCLUSIONS: There is an independent association between depression and measured hearing loss in older Chinese but not between depression and self-reported hearing loss. Self-reported hearing impairment should not replace audiometry in estimating risks of hearing impairment. The use of hearing aids could improve the general well-being of our older population.