Showing papers in "Southern Medical Journal in 1982"

Natural history of the retained surgical sponge.

Abstract: Retained surgical sponge is an infrequently reported condition that may be recognized incidentally during the early postoperative period, produce serious complications, or remain dormant for years. Clinical manifestations of the retained surgical sponge are a function of bacterial contamination and of the location of the sponge within the body cavity. Few sequelae follow external extrusion but internal erosion may lead to abscess, fistulas, and intestinal obstruction. Prevention requires constant sensitivity of the surgeon to this potential threat to the safe practice of surgery. The surgeon must account for an incorrect sponge count by adequate examination of the operative field and by roentgenographic studies when the issue remains in doubt. A correct sponge count does not fully preclude a retained sponge, however, and inspection of the operative field should be routine in all patients at risk.

Pheochromocytoma: clinical diagnosis and management.

Abstract: The incidence of pheochromocytoma among the hypertensive population is less than 1%. One third of the patients have intermittent hypertension, one third have remittent hypertension, and one third have persistent hypertension. The most common symptoms accompanying paroxysms include palpitatio

Preoperative hair removal: a random prospective study of shaving versus clipping.

Abstract: We report the results of a random, prospective study of electrical clipping versus routine razor shaving in the removal of hair immediately before operation. Two hundred patients having elective inguinal herniorrhaphy according to strict protocol were included in this study. Unsatisfactory skin preparation, as evidenced by gross cuts made in the skin during hair removal, was noted in 7% of those shaved and 4% of those clipped. Two subcutaneous wound infections occurred in the shaved group (2%) and one in the clipped group (1%). This study indicates that preoperative clipping of hair with electric barber's clippers immediately before operation is a safe, well tolerated procedure that does not increase the risk of postoperative wound infection.

Prescribed and nonprescribed drug use in an ambulatory elderly population.

Abstract: Drug usage was studied in an ambulatory geriatric population. Prescription and nonprescription drug use is described for 3,192 participants in a geriatric screening program (the Dunedin Program). Average drug use by these participants was found to be 3.2 medications. The use of both prescription and nonprescription drugs was higher for the women than for the men. In this population, drug use by both men and women increased with age, and this increase was mainly due to an increased use of prescription drugs. Participants were found to be taking numerous multiple-ingredient drug products.

Medical illness in psychiatric patients: barriers to diagnosis and treatment.

Abstract: We report a study of 102 consecutive admissions to the acute medical care unit of a large psychiatric hospital. The study was designed to investigate the epidemiology and the barriers to diagnosis and treatment of medical illness among female psychiatric inpatients. The majority of the patients were transferred to the unit because of nonspecific changes in physical condition or for behavioral differences. More than 70% of the patients were unable to communicate adequately with the physician. Ninety-two percent of the sample were found to have at least one with an average of three previously undiagnosed physical diseases not predicted by their symptoms on referral. We advocate a high index of suspicion of physical disease in the psychiatric population, and recommend an aggressive multidisciplinary diagnostic and therapeutic approach.

Clindamycin versus nafcillin or methicillin in the treatment of Staphylococcus aureus osteomyelitis in children.

Abstract: The treatment of osteomyelitis due to Staphylococcus aureus was evaluated by randomized trial in 12 children who received clindamycin and 13 children who received nafcillin or methicillin. In the nafcillin/methicillin group, the mean duration of intravenous (IV) therapy was 27 days (range 14 to 38 days) plus 3.7 weeks (range 0 to 8 weeks) of oral therapy with dicloxacillin. In the clindamycin group, the mean duration of IV therapy was 5.8 days (range three to ten days) plus 4.7 weeks (range three to nine weeks) of oral therapy with clindamycin. The geometric means (GMs) of peak serum bactericidal titers for IV therapy were 45 (range 16 to 256) and seven (2 to 256) for nafcillin/methicillin and clindamycin respectively. The GMs of peak serum inhibitory and bactericidal titers for oral therapy with clindamycin were 99 (range 16 to 512) and four (range 1 to 128) and were generally within one dilution of the IV titer. The outcome of therapy was excellent for ten children in the nafcillin/methicillin group and for 11 children in the clindamycin group. In the clindamycin group, the outcome did not correlate with achieving a peak bactericidal titer of greater than 1:8. Clindamycin administered IV until the patient is afebrile for three consecutive days and then orally for approximately four weeks is an alternative to nafcillin/methicillin in the therapy of S aureus osteomyelitis in children.

Obstructive sleep apnea after lateral medullary syndrome.

Abstract: Sleep apnea occurring in association with neurologic lesions is usually of the central type. We have described a patient in whom obstructive sleep apnea followed a lateral medullary syndrome. We hypothesize that the upper airway obstruction during sleep was due to weakness of the palatal and pharyngeal muscles resulting from the neurologic lesion. The patient initially had reduced respiratory center motor output (mouth occlusion pressure) which increased significantly after tracheostomy. We conclude that obstructive as well as central apnea may follow neurologic lesions. Each patient should be carefully evaluated to provide proper treatment.

Multiple cholesterol emboli syndrome.

Abstract: Of four patients with the syndrome of multiple cholesterol emboli (MCES), three had acute renal failure. One patient recovered stable renal function. A radiocontrast study preceded three of the cases. All four patients exhibited the "purple toe" livido reticularis syndrome. Three had a previously unreported findings--necrosis of the scrotum and foreskin of the penis, suggesting that penile and scrotal necrosis may be additional clues to the presence of MCES.

Acute pyelonephritis in the elderly.

Abstract: We did a prospective study of the clinical, laboratory, radiologic, and therapeutic features of acute, symptomatic, bacterial pyelonephritis in 35 consecutive elderly, noncatheterized patients who required hospitalization. Pyelonephritis had been identified as the most common cause of gram-n

Declining mortality from hypertension and stroke.

Abstract: Recorded mortality from hypertension and stroke has decreased dramatically in most countries during the last 50 to 75 years. The reported reduction in mortality may be due to changes in diagnostic fashions or coding procedures. However, the magnitude and consistency of the decline suggests the occurrence of a true decrease. The possibility that better treatment of hypertension is responsible for the reduction in mortality is attractive. However, based on temporal relationships, it seems more likely that much of the fall has resulted from an alteration in the determinants of blood pressure. Increasing use of antihypertensive drug therapy may account for an acceleration in the decline of stroke mortality during the last decade. If so, this represents one of the first tangible benefits of the massive public health efforts to detect and treat hypertension in the community.

Metastasis from squamous cell skin cancer of the extremities

Abstract: In a series of patients with localized squamous cell skin cancer treated at a cancer center, the incidence of metastasis was 1.4%. A premalignant condition, including thermal burns and irradiation dermatitis, was found in 30% of those patients, and 28% had multiple primary skin cancers. Forty-two of the 106 patients with metastasis had experienced local treatment failures, suggesting that such patients may be at greater risk of metastasis. In all but one instance of metastasis occurring from squamous cell skin cancer of the extremities, the regional lymph nodes were involved. Despite aggressive therapy, the five-year survival of patients with nodal metastasis was only 39%. Extracapsular spread of nodal disease was of grave significance. Based on the experience with metastatic squamous cell skin cancer of the head and neck, it is proposed to evaluate the adjunctive use of preoperative or postoperative irradiation and surgery in the treatment of metastatic squamous cell cancer of the skin of the extremities. Careful follow-up of patients with squamous cell skin cancer is necessary, and the lethal potential for recurrence and regional metastasis must be recognized.

Pulmonary function changes after acute inhalation of chlorine gas.

Abstract: Four young healthy adults were studied physiologically after accidental inhalation of chlorine gas. All patients were symptomatic with cough, tightness in the chest, and shortness of breath. All had restrictive ventilatory defect with impaired diffusing capacity. There was evidence of some obstruction in small airways. There was inconsistent evidence of obstruction in large airways. All lung function impairment was temporary and cleared entirely within one month. There was no residual lung damage. Language: en

Surgical decompression after cerebral hemispheric stroke: indications and patient selection.

Abstract: Decompressive craniotomy has a place in acute hemispheric infarctions. Patient selection should be guided by CT to exclude those with huge dominant hemispheric lesions that make reasonable neurologic recovery unattainable. Intracranial pressure monitoring should reduce the severity of neurologic sequelae by providing earlier, more timely operative intervention.

Sexual function after surgical and radiation therapy for cervical carcinoma.

Abstract: One hundred women treated for carcinoma of the cervix were interviewed more than one year later to establish the effects of radiation or surgical therapy on sexual function. Forty-three had received irradiation, 44 nonradical surgery, six combined surgery and irradiation, and seven radical surgery. The irradiation and nonradical surgery groups were each further subdivided into subgroups of patients aged 30 to 49 for age-controlled comparison. Patients in the irradiation group had statistically significant decreases in sexual enjoyment, ability to attain orgasm, coital opportunity, frequency of intercourse, and coital desire. The group who had nonradical surgical procedures had no significant change in sexual function after treatment. Similar results were found in both age-controlled subgroups, eliminating age as a major etiologic factor. Marked vaginal alterations were recorded in the majority of irradiated patients, but were not present among the groups treated with nonradical surgery. The vaginal changes alone could not be held accountable for the significant decrease in sexual function among women who received pelvic irradiation. The origin of decreased sexual desire after radiation therapy is complex, and not yet completely understood. We propose therapeutic programs to help women deal with the emotional and physical consequences of pelvic irradiation.

Pyogenic arthritis: emphasis on the need for surgical drainage of the infected joint.

Abstract: A ten-year retrospective review of patients with acute hematogenous pyogenic arthritis at the Duke University Medical Center yielded 14 affected joints in the pediatric group and 32 in adults. Follow-up ranged from six months to eight years. Analysis of factors possibly affecting end results included the joint involved, organism, duration of infection, antibiotics used, age of the patient, and mode of drainage--whether surgical or by needle aspiration. Surgical drainage in the pediatric group yielded uniformly excellent results. In adults, needle aspiration correlated with increased mortality and morbidity. In contrast to other series in the medical literature we found the indications for needle aspiration to be highly restrictive, and we recommend surgical drainage and appropriate antibiotics as the treatment of choice for most patients with pyogenic arthritis.

Sleep apnea syndromes.

Abstract: The sleep apnea syndromes have been recognized clinically in the United States only within the past ten years. The true extent of the problem is not known, but it seems certain that these syndromes are much more common than was generally assumed five years ago. Every clinician should be aware of the signs and symptoms of sleep apnea because of the rapid and prompt response to therapeutic measures. Sleep apnea syndromes, whether obstructive or central, can result in systemic or pulmonary hypertension, arterial blood gas abnormalities, life-threatening cardiac arrhythmias, chronic respiratory failure, sleep disturbances, narcolepsy, excessive daytime somnolence, sexual dysfunction, and the suspicion of mental retardation. The immediate and dramatic improvement produced by tracheostomy in the obstructive type of sleep apnea, or nocturnal ventilatory support in the central type, can not only enhance the quality of life for these patients, but return them to functional and productive lives.

Acute cardiogenic pulmonary edema in the elderly: factors predicting in-hospital and one-year mortality.

Abstract: This prospective evaluation of 55 consecutive patients, aged 60 years or older, admitted in 1977-1978 to a community hospital coronary care unit for treatment of cardiogenic pulmonary edema, examines morality during hospitalization and during the subsequent one-year follow-up. Their treatment was based on clinical criteria, without the "advantage" of Swan-Ganz catheters and before widespread use of vasodilators for severe congestive heart failure. Multiple clinical and laboratory features were reviewed to determine possible prognostic clues. The nine patients who died during the initial hospitalization provided several clues to immediate mortality, including admission systolic blood pressure of less than 150 mm Hg, dyspnea for more than four hours, and peak creatine kinase values greater than 1,000 IU/L. The study identified high-risk patients who may benefit from more aggressive in-hospital therapy. The one-year mortality among the 46 patients discharged from the hospital was high (43%). Most noninvasive methods were not useful in attempting to predict one-year survival. The important question of whether newer therapeutic methods including vasodilators will favorably alter the relatively poor long-term prognosis in the elderly needs further study.

Bacterial meningitis without clinical signs of meningeal irritation.

Abstract: A clinical diagnosis of meningitis in neonates is difficult because of paucity of physical findings. In older infants and children, nuchal rigidity, Kernig's or Brudzinski's sign, or bulging fontanelles are sought. A review of 1,064 cases of bacterial meningitis beyond the neonatal period revealed that 16 (1.5%) patients had none of those meningeal signs during the entire hospitalization, despite CSF pleocytosis. Eight patients (50%) were 2 years old or older. Lumbar punctures were done because of unexplained fever, changes in behavior or mental status,, seizures, or occurrence of skin petechiae in febrile patients. These patients frequently had moderate pleocytosis and all survived. The meningitis was caused by Neisseria meningitidis in seven patients, Haemophilus influenzae in six, Streptococcus pneumoniae in two, and Salmonella enteritidis in one patient. CSF should be examined in a patient of any age whenever meningitis is a consideration, even if patients lack meningeal signs.

Dinitrophenol poisoning: a diagnosis to consider in undiagnosed fever.

Abstract: A 32-year-old farmer had signs and symptoms of dinitrophenol poisoning after crop spraying with a herbicide containing derivatives of 2,4-dinitrophenol. Dinitrophenol causes toxicity by the uncoupling of oxidative phosphorylation in the mitochondria of cells throughout the body. In man the c

Villonodular synovitis: pigmented and nonpigmented variations.

Abstract: During the past 20 years, 34 cases of pigmented villonodular synovitis have been seen at Jackson Memorial Hospital, University of Miami Medical Center. There were 18 cases in the knee, eight in the hip, one in the elbow, two in the finger, three in the ankle, one in the wrist, and one in the sternoclavicular joint. In reviewing the pathology slides, it was difficult to differentiate fibrous histiocytoma from villonodular synovitis. The cause is considered to be inflammatory. The treatment is subtotal synovial resection with joint replacement as necessary. Recurrences after synovectomy are rare, with none in our series of 34, and only two cases lost to follow-up. I believe synovectomy and debridement to be the treatment of choice, although in the hip, the more destructive pressures involving the acetabulum may force the replacement of the total joint. Radiation therapy has not been used in the treatment of this condition at the University of Miami.

Dementia: the search for treatable causes.

Abstract: Of 100 consecutive cases of dementia, 23 were found to be of treatable or reversible causes. Many of these patients had been labeled as having “senile dementia” and some were en route to chronic care facilities. The implications of overlooking a treatable cause of dementia are obvious but cannot be

Systolic hypertension and complications of carotid endarterectomy.

Abstract: Systolic hypertension after carotid endarterectomy is frequently a serious problem associated with increased mortality and increased incidence of neurologic deficit. While this association is well reported, the authors of most series have been unable to determine whether the neurologic deficit was the cause or result of postoperative hypertension. From October 1978 to August 1981, 41 consecutive symptomatic patients who had carotid endarterectomy were examined with regard to hypertension control. The incidence of preoperative hypertension was 59%. All hypertension was controlled preoperatively in the hospital. Postoperative incidence of hypertension was 64%. Rigid control of blood pressure during the operative procedure and postoperative period was obtained with sodium nitroprusside. There was no mortality and no patients in this group had neurologic deficits. Our conclusion is that while the success or failure of the carotid endarterectomy is known to be multifactorial, this small group of patients indicates the need for rigid control of blood pressure in improving overall results.

New perspectives on coronary artery disease in hemodialysis patients.

Abstract: Between July 1, 1979, and July 1, 1980, we treated 64 patients with long-term maintenance hemodialysis. Of these, 11 (17%) had angina pectoris, four of them (6%) chronic stable angina and seven (11%) new onset of crescendo angina. The most common risk factors in the group with unstable angina were cardiomegaly and hypertension. Of the five patients who underwent cardiac catheterization, proximal occlusive disease was seen in four and these four had good left ventricular function. Three patients underwent coronary artery bypass, which successfully improved their functional status to a class I or II without any antianginal medicines. Concurrent hemodialysis was performed during heart-lung bypass in one patient. The need for dialysis postoperatively was easily delayed for 72 hours without detriment to this patient. We reached the following conclusions: (1) The prevalence of angina in a stable hemodialysis population was 17% in a one-year analysis period. (2) The incidence of new onset of crescendo angina, which potentially requires coronary angiography, was 11% over the same one-year period. (3) The presence of surgically correctable lesions in these cases is high. (4) Concurrent hemodialysis during coronary artery bypass simplifies postoperative fluid and electrolyte management and prevents surgical bleeding.

Undergraduate medical education for primary care: a case study in New Mexico.

Abstract: To address the dual problems of maldistribution of physicians and an increasing need for physicians who are lifelong learners, an experimental curricular track was developed at the University of New Mexico School of Medicine. Increased student responsibility for learning is encouraged by student-centered, small-group, problem-based tutorial learning, and early, primary care role modeling is offered during an early, lengthy, rural preceptorship. Preliminary outcomes reveal there is reinforcement of career interest in rural primary care with important linkages forged between the university and communities as a program by-product. Further, the experimental students, as compared to students in the conventional track, showed a greater appreciation of their learning environment, showed less stress, and failed to become cynical. The reorientation of undergraduate medical education toward the future health care needs of communities and the learning needs of physicians may require major modifications of curriculum design and role modeling experiences.

Hyponatremia in Patients With Schizophrenia

Abstract: Although there is a definite association between hyponatremia and schizophrenia, the true incidence and etiology have not been established. This report is a retrospective study of all admissions to the Baroness Erlanger Hospital over a three and one-half year period. There was a 5.8% incidence of hyponatremia in patients with schizophrenia as compared with a 0.36% incidence for all admission (P less than .01). Schizophrenic patients at risk for developing hyponatremia drank water excessively(P less than .01) and were most likely to be taking thioxanthene (P = .05(4)) antipsychotic and anticholinergic medications (P Less than .01). Most schizophrenic patients admitted with hyponatremia had dangerously low serum sodium levels (less than or equal to 120 mEq) and showed severe neurologic dysfunction. This retrospective study compares the clinical features of schizophrenic patients who develop hyponatremia and those who do not. The possible role of antidiuretic hormone is discussed

Bacillus cereus endocarditis involving a prosthetic valve.

Abstract: A rare case of "late onset' endocarditis due to Bacillus cereus occurred in a 55-year-old man who had a Carpentier-Edwards heterograft valve. Combination therapy with gentamicin and clindamycin was administered as suggested by testing of minimal bactericidal concentrations for these antibiotics. Valve replacement was necessary because of a paravalvular leak. There was no recurrence after six weeks of therapy.