Showing papers in "Southern Medical Journal in 1980"

Fatal pulmonary embolism in cancer patients: is heparin prophylaxis justified?

Abstract: The incidence of fatal and nonfatal pulmonary embolism (PE) was evaluated in a series of 578 patients, to quantify the suspected higher risk in cancer patients of death from massive PE when compared with patients not having cancer. PE occurred in 13% and was fatal in 8% of noncancer patients. It occurred in 17% and was fatal in 14% (P less than .05) of cancer patients. Of these cases of PE, 75% occurred in patients with adenocarcinoma and 62% in those having tumors of the pancreas, breast, large bowel, prostate, lung, and ovary. One of every seven hospitalized cancer patients died not of cancer but of PE, and 60% of all patients who died of massive PE had localized cancer or limited metastatic disease which would have allowed for reasonably long survival in absence of lethal PE. Accordingly, we strongly suggest use of prophylactic anticoagulation in hospitalized cancer patients having otherwise good prospects for reasonably long survival.

Etiologic factors of the Stevens-Johnson syndrome.

Abstract: We present a retrospective analysis of etiologic factors in 54 cases of Stevens-Johnson syndrome (SJS) diagnosed at Johns Hopkins (1966 to 1976). Our previous study, completed there in 1965, served as a model and data base for comparison. Analysis of the clinical presentation and epidemiologic data in this study reveals no major changes since the earlier series. Although difficult, a decision about cause was made in 82% of the cases. The remainder were considered idiopathic. Drugs and infections are especially suspect as etiologic agents in SJS, but we found no evidence to support one over another. Allergic predisposition, noted in 31% of our cases, may have played a role in the development of SJS. Indeed, the Stevens-Johnson syndrome may have an allergic basis with drugs and infectious agents as sensitizing antigens.

Prevalence of clinical gallbladder disease in Mexican-American, Anglo, and black women.

Abstract: Clinical observations have suggested that gallstones are increased in frequency in Mexican-Americans compared to other ethnic groups. Past autopsy surveys have demonstrated a low prevalence in blacks compared to whites. We retrospectively reviewed 1,018 charts to study the prevalence of cholelithiasis in ambulatory women of these three racial/ethnic backgrounds. Mexican-American women were found to have a prevalence of gallbladder disease approximately three times that of black women, with Anglo prevalences falling in an intermediate range. The prevalence of cholelithiasis was also positively associated with increasing age and diabetes, but not with serum cholesterol, use of oral contraceptives or conjugated estrogens, parity, hypertension, menstrual status, or smoking. An association with obesity was shown but could not be shown to be independent of other risk factors.

High-pressure injection injuries to the hand.

Abstract: Despite their appearance for over 20 years, high-pressure injection injuries to the hand are often grossly undertreated or mistreated, resulting in usually avoidable permanent impairment--often with amputation. Primary care physicians, and especially emergency room physicians, must be aware of the serious nature of this usually innocuous-appearing injury and immediately refer such patients for definitive emergency surgery. Language: en

Laboratory diagnosis of Rocky Mountain spotted fever.

Abstract: To examine the use of the laboratory in the diagnosis of Rocky Mountain spotted fever and to determine the specificity and sensitivity of the Weil-Felix test, hemagglutination, complement fixation, and skin biopsy immunofluorescence in the hospital, we reviewed our experience during th year 1978. Sera were submitted from 142 patients and skin biopsies from 16 patients suspected of having RMSF. Sensitivity rates of methods in the acute phase were skin biopsy, 70%; Proteus OX-19 agglutination, 65%; hemagglutination, 19%; Proteus OX-2 agglutination, 18%; and CF, 0%. Overall specificity rates were skin biopsy, 100%; hemagglutination, 99%; and agglutination of Proteus OX-2 96% and OX-19 78%. Major problems were failure to submit convalescent serum and nonspecificity of Weil-Felix titer of 1:160. Two cases illustrate the importance of skin biopsy and serologic results. Immunofluorescent examination of skin biopsies for Rickettsia rickettsii is the best procedure currently available for early diagnosis.

Infectious complications in renal transplant recipients.

Abstract: Infections complicated the course of 59 of 111 renal transplantations (53%) performed on 93 patients at the University of Maryland Hospital. Infections and resultant deaths were more common among the patients with cadaver transplants. The transplant wound and the urinary tract were the most common sites of infection, occurring in 33% and 24% respectively. Septicemia developed in 11 patients (10%), secondary to urinary tract infection in six and to surgical wound infection in three. Opportunistic viral, fungal, and actinomycotic infections occurred in ten patients (9%). A total of nine patients (8%) died as a result of infection. This experience with sepsis and mortality, substantially lower than previously reported, may have resulted from (1) rigorous screening and detailed histories of recipients and donors for infection at the time of transplantation, as well as bacteriologic and serologic studies; (2) discontinuation of azathioprine whenever the WBC fell to less than 5,000/cu mm; (3) aggressive surveillance and early management of infections; and (4) prompt removal of a nonviable kidney when detected by radionuclide scan and percutaneous renal biopsy.

Renal agenesis after first trimester exposure to chlorambucil

Abstract: One of a set of twins aborted at 20 weeks' gestation had unilateral renal agenesis after exposure to chlorambucil and prednisone since conception. There are no firm clinical data suggesting that second or third trimester exposure to any of the immunosuppressive drugs is toxic to the fetus, and no absolute cause-and-effect relationship is established in this case.

Effect of diabetes upon penile sympathetic nerves in impotent patients.

Abstract: Samples of erectile tissue taken from the corpora cavernosa of 16 male diabetic patients suffering from impotence were studied. The content of norepinephrine, which reflects sympathetic nerve activity of that tissue, was significantly lower in insulin-dependent patients 104.2 +/- 24.8 (SE) pg/mg wet weight (P less than .001) and diet-controlled patients 483.7 +/- 103.7 (P less than .01) than the normal men (881.7 +/- 62.0). Myelinated and unmyelinated nerve fibers were observed intact and unaltered in each group of patients. The results indicated that normally a dense adrenergic innervation of human erectile tissue is present, but that a reduction occurs in norepinephrine content in diabetic patients with impotence. It appears, however, that the anatomic integrity of the sympathetic nerves is intact. The presence of intact nerve fibers along with a diminished content of neurotransmitter suggests the possibility of pharmacologic treatment of impotence.

Acute febrile juvenile rheumatoid arthritis in adults: cause of polyarthritis and fever.

Abstract: Acute febrile juvenile rheumatoid arthritis (JRA) of adult onset is often diagnosed by ruling out other problems. The classification of JRA is primarily based on the distinct type of onset, of which there are usually three: (1) acute febrile or Still's type, (2) polyarticular, and (3) monoarticular pauciarticular arthritis. Fever of unknown cause is frequently the initial symptom. This type of arthritis may be characterized by any or all of the following: unexplained high fever, rash, weight loss, lymphadenopathy, splenomegaly, pericarditis, pleurisy, pneumonitis, abdominal pain, myalgias, arthralgias, arthritis, sore throat, leukocytosis, anemia, circulating immune complexes, liver test abnormalities, and carpal-metacarpal and tarsal-metatarsal fusion. Patients often respond dramatically to anti-inflammatory agents. Corticosteroids, gold salts, penicillamine, and cytotoxic drugs have been effective for certain patients. The prognosis of the disease has been generally favorable. Although symptoms may recur, remission can be prolonged.

Hyponatremia and rhabdomyolysis: a possible relationship.

Abstract: A 40-year-old schizophrenic presenting with an acute toxic psychosis was found to be severely hyponatremic with a serum osmolality of 217 mOsm/kg. The patient was combative and required physical restraints. Shortly after admission the patient's serum transaminase level was elevated, and the next day the CPK value was 175,000 IU. In addition, his serum and urinary myoglobin levels were markedly raised. Shortly after rhabdomyolysis was diagnosed, the patient developed reversible acute renal failure presumably secondary to the myoglobinuria. This report examines the possibility that the severe hyponatremia and hypoosmolality caused his skeletal muscles to become potassium depleted, leading to rhabdomyolysis during the stenuous exercise involved in his battling the restraints.

Intranasal steroid injection during pregnancy.

Abstract: Nasal obstruction during pregnancy may arise from allergic or endocrine factors and is often compounded by abuse of topical nasal vasoconstrictors. Severe nasal symptoms occurred in 32% of pregnant women surveyed. Despite self-medication with nose drops and proprietary remedies, as well as prescript

Sparganosis: clinical and pathologic observations in ten cases.

Abstract: Sparganosis is an infection, usually of subcutaneous tissues, caused by the larva of a tapeworm of the genus Spirometra. Approximately 55 cases have been reported in this country, almost exclusively from the Southeastern states. We report an additional ten cases, all of which presented as a single s

Religious life of alcoholics.

Abstract: It has been documented that alcoholics often become abstinent after a religious experience. We have inquired into the religious teachings, beliefs, practices, and experiences of a group of chronic alcoholics. It was observed that alcoholics were less involved in religious practices, had less exposure to religious teachings, had fewer religious experiences, and withdrew from religion more frequently during adolescence than did a group of normal subjects. It is concluded that early-life religious experiences of an alcoholic are most conflictual and lead to religious confusion rather than commitment.

Safety and efficacy of long-term diazepam therapy.

Abstract: Clinical evidence of withdrawal phenomena and efficacy was studied in 23 long-term users of diazepam (15 to 60 mg daily). No withdrawal reactions were observed in the ten patients who received placebo in a double-blind fashion for a two-week period. Changes in anxiety scores of both patients who rec

Postpartum dissecting aneurysm of coronary arteries in a patient with sarcoidosis.

Abstract: We have described a case of sudden death in a 27-year-old woman, 16 days postpartum, resulting from a dissecting aneurysm of the right and left coronary arteries. The patient also had multiorgan sarcoidosis. Postpartum coronary artery dissecting aneurysm appears to be caused by weakening of the media, resulting from the loosening of the ground substance during pregnancy and the hemodynamic changes occurring during and after delivery.

Infective Endocarditis in the Elderly

Abstract: We reviewed 56 cases of infective endocarditis (IE) in patients 65 years of age and older. The clinical features, laboratory manifestations, and bacterial etiology of IE in our patients were similar to those in younger patients. Ninety-three percent were febrile, 86% had heart murmurs, and 36% had p

Malignant melanoma associated with breast cancer.

Abstract: The experience of the population-based Connecticut Tumor Registry was analyzed for the occurrence in the same patient of breast cancer and malignant melanoma. A total of 18,010 women with breast cancer were followed up for the subsequent development of malignant melanoma of the skin or eye. Similarly, 835 women with cutaneous or ocular malignant melanoma were followed up for the subsequent development of breast carcinoma. Survival experience for these cohorts and appropriate Connecticut Tumor Registry incidence rates were used to calculate an expected number of individuals with both types of malignant neoplasms. Twenty-three women had both types of tumors diagnosed at least one month apart. Fewer than 14 such occurrences were expected (P < .05). The two tumors may be related through hormonal factors, particularly when considered with regard to the findings of other laboratory and epidemiologic studies.

Primary carcinoma of the male urethra.

Abstract: Of 27 men with primary urethral carcinoma, 11 had tumors that rose at or anterior to the penoscrotal junction; 16 had tumors arising between the membranous urethra and the penoscrotal junction. Surgery was the only effective definitive therapy, and only palliative methods could be used for half of those patients with posterior tumors. A good prognosis was possible if primary treatment controlled the malignant process, but all patients in whom tumor recurred locally eventually died of their disease.

Depression in family practice patients.

Abstract: Multiple factors have been described as significant contributors to depression in medical patients. This study attempts to assess the relative significance and interrelationship of variables associated with depression. A group of 199 family practice patients were studied. Using a multivariate research design, significant depressive symptoms were found in 41% of the sample. A stepwise multiple regression analysis revealed that the five most important factors associated with depression, in order of significance, were socioeconomic status, recent stress, use of birth control pills, serious physical illness, and distant life events. This study supports the thesis that depression is a final common pathway syndrome in which biologic and social forces coalesce into syndrome expression. The primary care practitioner needs to be aware of the multiple risk factors for depression to develop effective detection and intervention strategies.

Morphologic types of breast cancer: age, bilaterality, and family history.

Abstract: Morphologic type is not generally included in the study of cancer risk factors. In breast cancer, attention is being given to age at diagnosis. In this study cases were analyzed by morphologic type as well as age at diagnosis for occurrence of bilateral disease and for family history of breast cancer. Of the morphologic types which were more frequent in younger patients--lobular in situ, medullary, and intraductal comedo--only lobular in situ had an increased frequency of bilaterality (fourfold increase). Of these, only patients with intraductal comedo reported familial breast cancer more frequently than the average. Lobular infiltrating carcinoma is diagnosed more frequently in elderly patients and is associated with 2.6 times more bilaterality and increased familial risk. Diagnosis at age 45 to 54 is also associated with increased bilaterality, but the diagnosis of lobular carcinoma has much stronger association with bilaterality than early age at diagnosis. Because of the high risk of bilaterality in lobular neoplasia and in those with a family history of cancer occurring before the menopause, bilateral biopsies and subsequent screening for malignancy should be done in these women.

Arrest of severe liver hemorrhage by an omental pack.

Abstract: From Jan 1, 1971 through June 30, 1979, 113 cases of massive liver injury were managed by insertion of a viable omental pack. Significant active hemorrhage was present in all cases, while the source of hepatic bleeding was primarily venous in the 102 injuries due to blunt trauma. Associated injuries were present in 90% of patients, with an average of 2.4 associated injuries per patient. A total of 175 complications developed in 82 patients. Nine deaths produced a mortality of 8%. Arrest of liver hemorrhage by tamponade with viable omentum was almost uniformly successful in patients with nonpenetrating injury.

Plasma Cell Granuloma of the Lung: Endobronchial Presentation and Absence of Response to Radiation Therapy

Abstract: Plasma cell granuloma of the lung is an uncommon, slow-growing, benign “pseudotumor” morphologically and clinically distinct from malignant plasma cell tumor (plasmacytoma). Its histopathology is distinct from sclerosing hemangioma and pseudolymphoma. Most are located in lung parenchyma, but a few p

Spontaneous vitreous hemorrhage: etiology and management.

Abstract: Spontaneous vitreous hemorrhage, without trauma, accounted for 317 patients (375 eyes) seen during a four-year period from July 1, 1975, to June 30, 1979. The most common causes were proliferative diabetic retinopathy, 39.2%; retinal tear, 12.1%; posterior vitreous detachment, 12%; vein occlusion, 10.4%; retinal detachment, 6.7%; intraocular lens, 3.2%; proliferative sickle retinopathy, 1.3%; miscellaneous, 7.4%; and unknown, 6.7%. Emphasis is placed on the importance of establishing the specific cause so that specific therapy may be instituted.

Meige’s syndrome

Abstract: We present two women with Meige's syndrome, a condition in which the clinical presentation differs from tardive dyskinesia by the lack of exposure to neuroleptic drgus, greater severity of blepharospasms, and more prolonged dystonic contractions of oromandibular muscles. In this condition we used triaxial accelerometry to detect dystonia, which may also appear in limb and respiratory muscles. Although psychologic factors may affect the symptoms, the basic pathogenesis of this syndrome does not seem to be psychogenic. We think that biochemical abnormalities in the basal ganglia are responsible for the dyskinesias and submit data suggesting a reduction of dopamine turnover in the central nervous system of one patient. Both patients have evidence of autoimmune diseases, and one patient's dystonic movements responded to immunosuppressive therapy, suggesting that autoimmune processes contribute to the pathogenic mechanism of Meige's syndrome in some instances.

Coexistence of systemic lupus erythematosus and myasthenia gravis

Abstract: The coexistence of myasthenia gravis and systemic lupus erythematosus in a 52-year-old woman is reported. Review of the literature shows that systemic lupus erythematosus occurs much more often in the myasthenia gravis population than in the population in general. Myasthenia gravis should be considered in the differential diagnosis in a patient with weakness and systemic lupus erythematosus.

Articular and skeletal infections caused by Pasteurella multocida

Abstract: Pasteurella multocida infections of joints and bones generally occur in individuals who have contact with cats or dogs. Osteomyelitis usually follows penetrating trauma such as an animal bite. Septic arthritis tends to occur in patients who have preexisting inflammatory joint disease, especially if a systemic condition which is known to predispose to infection is present. The principles of therapy for septic arthritis or osteomyelitis are no different from those which have been established for other infecting organisms. Although P multocida is susceptible in vitro to penicillin, treatment of septic arthritis with this drug is still associated with a slow therapeutic response.

Pseudomonas infections of the foot after puncture wounds.

Abstract: Evaluation of ten children with Pseudomonas bone and joint infections resulting from puncture wounds of the foot identified a definite pattern to sequelae. The longer the symptoms were present before adequate treatment was instituted the greater was the risk of bone and joint destruction along with the development of chronic osteomyelitis. The syndrome usually does not produce systemic signs, but the patterns is characteristic and should be considered after any puncture wound of the foot in which the symptoms worsen instead of improving with time.