Showing papers in "Postgraduate Medicine in 1991"
TL;DR: The authors discuss thrombolytic agents currently available, examine the results of ongoing studies, and reflect on future developments in throm bolytic management of myocardial infarction.
Abstract: Should thrombolytic therapy be used in all patients who have acute myocardial infarction? Is one agent more effective than another? How safe is thrombolytic therapy? In this article, the authors discuss thrombolytic agents currently available, examine the results of ongoing studies, and reflect on future developments in thrombolytic management of myocardial infarction.
65 citations
TL;DR: The sexual addiction model enables physicians to understand the self-destructive behavior of patients whose actions may otherwise appear inexplicable and allows sex addicts to stop their compulsive behavior and improve their relationships.
Abstract: The sexual addiction model enables physicians to understand the self-destructive behavior of patients whose actions may otherwise appear inexplicable. When a person is preoccupied with sex and continues to engage in compulsive sexual activity despite adverse consequences (eg, loss of marriage, job, health, freedom), he or she is a sex addict. Treatment allows sex addicts to stop their compulsive behavior and improve their relationships. Preferred treatment includes professional counseling and attendance at self-help programs based on the Alcoholics Anonymous model. Partners of sex addicts, whose coaddiction may manifest itself through various physical symptoms, depression, or compulsions, can benefit from the same treatment approach.
65 citations
TL;DR: Regular aerobic exercise has significant cardiovascular benefits, including a reduction in incidence of and mortality from coronary artery disease--probably because of positive effects on blood lipid levels and blood pressure.
Abstract: Regular aerobic exercise has significant cardiovascular benefits, including a reduction in incidence of and mortality from coronary artery disease--probably because of positive effects on blood lipid levels and blood pressure. Aerobic exercise can also be an important adjunct to a weight-loss program. Many persons who continue an exercise program do so because of its positive mental benefits, including reduction in anxiety and depression and modulation of stress levels. Aerobic exercise has a place in the management of diabetes, pregnancy, and aging. The problems associated with aerobic exercise are minimal compared with its benefits.
53 citations
TL;DR: A warm, swollen foot in a diabetic patient with long-standing neuropathy without local or systemic signs of infection must be considered Charcot's disease until proven otherwise.
Abstract: PreviewPatients are usually quick to report an orthopedic problem because of the pain and disability it causes. That is what is so misleading about Charcot's disease. Pain is often absent, and the earliest signs of bone and joint destruction are unexplained swelling, warmth, and redness. In diabetic patients, Charcot's joint disease must be promptly ruled out or treated. Continued use of the affected foot can be very destructive. The authors summarize the approach that they find most useful at their diabetic referral clinic.
47 citations
TL;DR: Runners who have exercise-induced amenorrhea should be advised to decrease their training intensity to a level where menses resume, and Cyclic therapy with conjugated estrogens and progesterone should also be considered, as should daily calcium supplementation.
Abstract: PreviewAlthough once seen primarily in military personnel, stress fractures are now becoming increasingly common in athletes Incidence is especially high in amenorrheic runners Because this injury is underdiagnosed, a high index of suspicion should be maintained The authors recommend a thorough medical workup and modification of training regimen and risk factors A case of stress fracture in a 16-year-old athlete with exercise-induced amenorrhea is presented
45 citations
TL;DR: By making good use of opportunities for patient education, primary care physicians may positively influence the prognosis of several types of cancer, particularly breast cancer and malignant melanoma of the skin.
Abstract: Patient delay in seeking care for cancer symptoms is common and well documented by research studies. Fear and denial, lack of information about cancer, and financial considerations all contribute to this delay. Patient education may be an important factor in decreasing the length of delay and thereby improving treatment outcome. By making good use of opportunities for patient education, primary care physicians may positively influence the prognosis of several types of cancer, particularly breast cancer and malignant melanoma of the skin.
36 citations
TL;DR: Chilaiditi's syndrome should be considered in the differential diagnosis of abdominal and chest pain because this syndrome can be mistaken for more serious abnormalities, which may lead to unnecessary surgical intervention.
Abstract: PreviewChilaiditi's syndrome is a relatively common radiologic finding that may be confused with free air under the diaphragm or other chest or abdominal disorders requiring surgical intervention. Drs Haddad and Lacle describe a case in which a chest radiograph was initially misinterpreted before the correct diagnosis of Chilaiditi's syndrome was made.
33 citations
TL;DR: The breath hydrogen test is simple, noninvasive, accurate, and inexpensive and is the diagnostic method of choice for lactose intolerance.
Abstract: Lactose intolerance is a common condition that can cause nonspecific gastrointestinal symptoms. A reliable diagnosis cannot be made on the basis of the patient's history. The breath hydrogen test is simple, noninvasive, accurate, and inexpensive and is the diagnostic method of choice. In addition to traditional dietary restriction of lactose, treatment may consist of alterations in dietary fat content or caloric density to reduce symptoms and use of dairy products or additives that provide lactase activity.
28 citations
TL;DR: Using fine-needle biopsy to initially screen patients with nodules is a safe and accurate method for diagnosing thyroid nodules and can save substantially on healthcare resources.
Abstract: PreviewFine-needle aspiration biopsy can save healthcare costs by providing sensitive and specific results early in the diagnostic process. The authors explain how the method is used at their institution, including step-by-step instructions and follow-up guidelines based on their own experience.
26 citations
TL;DR: Drug fever should be considered in the differential diagnosis of any patient with unexplained fever, and clues in the history, physical examination, and laboratory assessment can point to the diagnosis.
Abstract: Drug fever should be considered in the differential diagnosis of any patient with unexplained fever. Clues in the history, physical examination, and laboratory assessment can point to the diagnosis before extensive, costly, and potentially harmful investigations and therapies are begun.
24 citations
TL;DR: The examination and treatment of a patient with C septicum infection in whom metastatic cancer was found on laparotomy is described.
Abstract: PreviewFor reasons that are not fully understood, there is an association between Clostridium septicum infection and carcinoma. In this article, Dr Kirchner describes the examination and treatment of a patient with C septicum infection in whom metastatic cancer was found on laparotomy.
TL;DR: In cases of acute unilateral facial weakness, a careful and systematic evaluation is necessary to identify the cause and administration of systemic oral corticosteroids may lessen severity and duration of symptoms.
Abstract: Facial paralysis can be caused by a remarkable number of underlying conditions, diseases, and injuries The list is daunting, but when every possibility except Bell's palsy has been excluded, the r
TL;DR: Hypertensive patients should be aware of the possible effects of nonprescription medications on blood pressure control and no adrenergic agents should be used.
Abstract: Hypertensive patients should be aware of the possible effects of nonprescription medications on blood pressure control. For absolute safety, no adrenergic agents should be used. Nasal phenylephrine hydrochloride is probably the safest of these agents, and pseudoephedrine hydrochloride may also be safe. Phenylpropanolamine hydrochloride and ephedrine sulfate are probably best avoided. The effects of other adrenergic agents (eg, epinephrine) on blood pressure have not been clinically evaluated. Ibuprofen may elevate blood pressure if taken in maximum over-the-counter doses for more than a few days. The ethanol and sodium chloride content of nonprescription drugs taken in recommended doses does not appear to pose a great hazard.
TL;DR: Many types of ocular trauma can be diagnosed and treated in the primary care office, particularly if a slit lamp is available, and a foreign-body spud greatly facilitate the removal of foreign bodies from the cornea.
Abstract: Many types of ocular trauma can be diagnosed and treated in the primary care office, particularly if a slit lamp is available. Treatment for corneal abrasions consists of applying a cycloplegic medication, antibiotic ointment, and a patch (unless a corneal ulcer is suspected). Iritis can be treated with cycloplegics and topical corticosteroids; the prescribing physician should be familiar with the potential ocular side effects and complications. Hyphemas are treated with bed rest, topical atropine sulfate drops and topical corticosteroids, as well as measures to prevent rebleeding. A slit lamp, topical anesthesia, and a foreign-body spud greatly facilitate the removal of foreign bodies from the cornea. Acid and alkali burns should be irrigated until the pH is normal and then should be treated like a corneal abrasion. Lid lacerations must be repaired with care to preserve proper functioning of the lid. Ruptures of the globe are serious injuries requiring surgical repair and long-term follow-up.
TL;DR: Drug-induced aseptic meningitis is a syndrome that should be considered in the differential diagnosis of acute and recurrent asepsis and resolves quickly following drug cessation.
Abstract: What are the signs and symptoms of drug-induced aseptic meningitis? How can it be differentiated from acute or recurrent aseptic meningitis that has some other origin, and which patients are most s...
TL;DR: The problems involved with the sliding-scale approach, cases in which it may be useful, and specific details to watch to improve its effectiveness are described.
Abstract: PreviewGiving hospitalized diabetic patients a set amount of insulin determined by their blood glucose level sounds like appropriate treatment. However, errors and inconsistencies can result with this method. As Dr Katz points out, several alternative insulin regimens are more scientifically sound and probably take no longer to implement. He describes the problems involved with the sliding-scale approach, cases in which it may be useful, and specific details to watch to improve its effectiveness.
TL;DR: In the vast majority of cases, the cause of microcytic hypochromic anemia is clearly suggested by the patient history, physical examination results, red cell indexes, and peripheral blood smear, and further diagnostic testing, if necessary, can be very selective.
Abstract: In the vast majority of cases, the cause of microcytic hypochromic anemia is clearly suggested by the patient history, physical examination results, red cell indexes, and peripheral blood smear. Thus, further diagnostic testing, if necessary, can be very selective. When the underlying cause of anemia is obscure, the serum ferritin concentration should be measured first. If it is normal or increased, serum iron and free erythrocyte protoporphyrin levels can be determined. The serum iron level is low in anemias caused by iron deficiency and chronic disease but normal or elevated in those resulting from the thalassemias, hemoglobin E disorders, and lead toxicity. The free erythrocyte protoporphyrin level is elevated with iron deficiency, the anemia of chronic disease, and lead toxicity but normal with thalassemias and hemoglobin E disorders. Results of these two test indicate which of the more specific tests is most likely to yield the correct diagnosis.
TL;DR: Patients with asymptomatic aortic stenosis and normal left ventricular function can be treated medically and followed with serial aortsic valve area determinations using Doppler echocardiography.
Abstract: Degenerative calcific aortic stenosis is evolving as a common geriatric problem. Once symptoms develop, it is a highly lethal disease that does not respond well to medical therapy. Aortic balloon valvuloplasty may offer palliation but is unlikely to alter the overall course of the disease. Aortic valve replacement is the therapy of choice, but high perioperative morbidity and mortality rates can be expected in the very elderly. The presence of other appreciable cardiac disorders may contribute to the occurrence of postoperative complications. Patients with asymptomatic aortic stenosis and normal left ventricular function can be treated medically and followed with serial aortic valve area determinations using Doppler echocardiography.
TL;DR: The use of alternative procedures and agents for reducing the pain of inducing anesthesia and thus reducing patients' anxiety are described.
Abstract: Fear of the needle is a real issue with some patients and may be an obstacle to inducing anesthesia before minor surgical procedures are performed. Adults may express this fear verbally or, out of embarrassment, even avoid coming to the physician's office. Children may become intensely anxious and hysterical. In this article, Dr Holmes describes the use of alternative procedures and agents for reducing the pain of inducing anesthesia and thus reducing patients' anxiety.
TL;DR: Self-monitoring of blood glucose is an important component of treatment in patients with diabetes and success of the process depends on the training, reassessment, and support of the patient by the healthcare team.
Abstract: Self-monitoring of blood glucose is an important component of treatment in patients with diabetes. Recent improvements in glucose meters have made patient self-testing more reliable and less dependent on user technique. However, success of the process depends on the training, reassessment, and support of the patient by the healthcare team.
TL;DR: Acute salicylate poisoning with enteric-coated aspirin may result from accidental ingestion, a suicide attempt, or a complication of long-term therapy.
Abstract: Acute salicylate poisoning with enteric-coated aspirin may result from accidental ingestion, a suicide attempt, or a complication of long-term therapy. Because absorption of enteric-coated aspirin is delayed, use of the Done nomogram to determine toxicity may lead to underestimating the severity of the poisoning. Treatment options include induction of emesis or diuresis, gastric lavage, administration of activated charcoal, and surgery. Language: en
TL;DR: Thrombocytopenia in hospitalized alcoholics may be caused by splenomegaly, folate deficiency, and, most frequently, a direct toxic effect of alcohol on production, survival time, and function of platelets.
Abstract: Thrombocytopenia in hospitalized alcoholics may be caused by splenomegaly, folate deficiency, and, most frequently, a direct toxic effect of alcohol on production, survival time, and function of platelets. Platelet count begins to rise after 2 to 5 days' abstinence from alcohol. The condition is generally benign, and clinically significant hemorrhage is rare.
TL;DR: The authors present a practical discussion of the topic, classifying reactions in terms of clinical presentation rather than pathophysiologic description, to recognize quickly whether the reaction is easily correctable or serious enough to force discontinuation or modification of treatment.
Abstract: PreviewAdverse reactions occur acutely or some time after the fact in 20% of all blood transfusions. Since reactions are so common, it is important to recognize quickly whether the reaction is easily correctable or serious enough to force discontinuation or modification of treatment. The authors present a practical discussion of the topic, classifying reactions in terms of clinical presentation rather than pathophysiologic description.
TL;DR: Children with a high risk for recurrence of seizures may benefit from continuous anticonvulsant prophylaxis.
Abstract: Febrile convulsions affect about 1 child in 30. Most of these children have a good outcome with no sequelae and do not require prophylactic medication. Differential diagnosis should include meningitis, epilepsy, hypoglycemia, and encephalopathies and other central nervous system disorders. Children with a high risk for recurrence of seizures may benefit from continuous anticonvulsant prophylaxis.
TL;DR: Atypical pathogens play an important role in the pathogenesis of community-acquired pneumonias and when typical and atypical pathogens are suspected, combination drug therapy is preferred until the diagnosis is firm and one of the two antibiotics can be dropped.
Abstract: Atypical pathogens play an important role in the pathogenesis of community-acquired pneumonias. Early definitive diagnosis is often difficult. Careful attention must be given to the patient's history and other diagnostic clues. When a specific pathogen seems very likely to be the cause, appropriate and cost-effective empirical therapy is best accomplished with a single-drug regimen. However, when typical and atypical pathogens are suspected, combination drug therapy is preferred until the diagnosis is firm and one of the two antibiotics can be dropped.
TL;DR: Intravenous nitroprusside sodium (Nipride, Nitropress) is probably the drug of choice for hypertensive emergencies other than those due to eclampsia or pheochromocytoma.
Abstract: PreviewIn a hypertensive emergency, the goal should be to reduce the critically elevated blood pressure to a safer, although not necessarily “normal,” level within an hour. The authors emphasize that prompt diagnosis, an understanding of the basic patho-physiology of hypertensive crisis, and familiarity with the pharmacology of available agents are essential for successful management.
TL;DR: Neuroleptic malignant syndrome has been described in patients receiving dopamine antagonists and in a few patients after withdrawal of dopaminergic antiparkinson therapy.
Abstract: Neuroleptic malignant syndrome has been described in patients receiving dopamine antagonists and in a few patients after withdrawal of dopaminergic antiparkinson therapy Complications affect almost all organ systems and can be life-threatening Most patients have fever, altered level of consciousness, bradykinesia, and rigidity Treatment includes withdrawal of the causative agent and supportive therapy for complications When withdrawal of a dopaminergic medication is the suspected cause, the agent should be reinstated
TL;DR: Many of the painful foot problems seen in adults are easily treated, and patients should be advised to change to shoes that provide plenty of room in the toe box and that minimize friction on painful areas.
Abstract: Many of the painful foot problems seen in adults are easily treated. Bunions and bunionettes often respond to a change to wide, soft-toed shoes or sandals and the temporary use of a mild anti-inflammatory agent. Initial treatment of plantar keratoses is trimming and use of cushioning shoe inserts. Diffuse keratoses may require reconstructive surgery if metatarsal deformity is the cause. Seed corns and soft corns respond to trimming, and alleviation of pressure with padding and wearing of open-toed shoes is beneficial in these lesions as well as in hard corns. Surgical resection of any underlying exostosis may be required for hard or soft corns or "pump bumps," which are caused by pressure from the shoe's heel. In all cases, patients should be advised to change to shoes that provide plenty of room in the toe box and that minimize friction on painful areas.
TL;DR: The butterfly rash and malar flush are common facial manifestations of several disorders and may be caused by graft-versus-host disease in a patient undergoing bone marrow transplantation.
Abstract: The butterfly rash and malar flush are common facial manifestations of several disorders. Systemic lupus erythematosus may produce a transient rash before any other signs. In pellagra, symmetric keratotic areas on the face are always accompanied by lesions elsewhere on the body. Erysipelas produces brawny, fiery red facial lesions, and scarlet fever causes facial eruptions as part of a generalized eruption. Lupus vulgaris and lupus pernio produce nodules that may spread in a butterfly pattern, and seborrheic dermatitis has a predilection for the malar prominences and other areas of the face. Carcinoid syndrome often causes flushing attacks that vary in duration, and facial flushing that lasts throughout treatment may accompany chemotherapy if the patient has a hypersensitivity reaction. Deep-red rashes and/or lichenoid lesions may be caused by graft-versus-host disease in a patient undergoing bone marrow transplantation.