Clinical Q&A - Renal tumours, dipstick tests andheadache

Our team of experts answer your questions on headaches, hypertension and urine tests.

Should we change patients from atenolol despite the fact their BP is well-controlled?

That is a difficult question to answer. The temptation is always not to rock a steady ship.

However, whenever atenolol has been compared with other agents in hypertension trials it has always tended to come off second best.

My approach is to consider what I would wish to take if I were hypertensive, and it would not be atenolol. Thus I tend to favour changing the patient to an alternative agent.

Dr Clark is a reader and honorary consultant cardiologist at Castle Hill Hospital, Cottingham, Northamptonshire

What characteristics of headache should prompt referral to exclude a space-occupying lesion?

Brain tumour and other space-occupying lesions (SOLs) usually present with focal epilepsy or with progressive neurological impairment.

In primary care the risk of brain tumour in patients with headache is about 0.1 per cent; in secondary care the risk is about 1 per cent.

Conversely, headache is very common, affecting 95 per cent of people in their lifetime, 75 per cent in a year, 3 per cent every day. Chronic headache is not caused by SOL.

The following features merit consideration of brain imaging - which does not necessarily require secondary referral.

First, worst, or thunderclap headache needs same-day A&E assessment with a view to CT brain scan followed, if normal, by lumbar puncture to look for xanthochromia.

Headache in patients known to have a cancer that metastasises to brain - those of the bronchus, breast, kidney, bowel, thyroid or melanoma - will require imaging.

Older people presenting with a headache need an ESR or CRP to rule out giant cell (temporal) arteritis. If these patients are to be given steroids, a temporal artery biopsy should always be performed as soon as possible, certainly within two weeks.

Headache that gets worse on exertion, stooping, coughing or similar.

In 10 per cent of cases this is caused by CSF obstruction, most commonly cerebellar tonsillar ectopia, which can be seen on MRI but not on CT.

Headache with abnormal physical signs such as papilloedema, ataxia, impaired consciousness, meningism, or hemiparesis obviously requires imaging.

Headache that gets worse on waking is traditionally said to be caused by raised intracranial pressure, although it is much more commonly caused by migraine and by medication overuse.

Other features which often trigger inappropriate concern include family history of brain tumour, severity of headache, long duration of headache, and lack of response to medication - which is usually the result of medication overuse, the commonest diagnosis for intractable headache.

Dr Giles Elrington, consultant neurologist, City of London Medical Centre, London

I have a patient with right ureteric tumour, but who has normal renal function. The plan is to remove the tumour and re-anastomose the ureter.

What is the prognosis for this?

This depends on the size and grade of the tumour - I presume that we are looking at a transitional cell tumour.

In general terms, small non-invasive tumours can now be managed by endoscopic resection, while larger tumours may need either local resection or nephro-ureterectomy (often carried out laparoscopically).

For superficial tumours an effective cure rate of between 60 and 70 per cent is suggested.

Sometimes chemotherapy or BCG immunotherapy will be used as an adjuvant.

Invasive tumours are treated by nephro-ureterectomy, unless the patient has renal failure, in which case a compromise is needed.

Mr Gordon Muir, consultant urologist at King's College Hospital, London

When I test an MSU with a dipstick before sending it to the lab, will the dipstick contaminate the sample?

Should I carry out the dipstick test on a separate sample?

A fresh dipstick should be sterile at the test end when it is picked out of the bottle. Therefore the risk of contamination should be slight unless it is immersed a long way into the urine or the fingers touch the surface of the sample or container in the process.

In an ideal world a separate sample would be best but the risk probably does not justify the effort. Delayed transport to the laboratory is far more likely to be a problem.

Dr Peter Wilson, consultant microbiologist at the Middlesex Hospital, London.

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