Showing papers in "Southern Medical Journal in 1984"

Chronic Mononucleosis Syndrome

Abstract: We present data on 14 patients with chronic symptoms of disabling fatigue in association with serologic evidence of active Epstein-Barr virus (EBV) infection. Two thirds were women, and the average age at onset was 29.6 years. Forty-three percent were known to have had previous infectious mononucleosis, but the usual criteria for that diagnosis were not helpful with the present syndrome. Eighty-six percent had serologic evidence of cytomegalovirus (CMV) infection. Profound immunodeficiency was not present, but 71% had partial hypogammaglobulinemia, and minor abnormalities of T cell subsets were noted in six of seven patients studied. Fifty-seven percent achieved temporary serologic and symptomatic remission after an average duration of 33 months. Only one patient has a sustained remission. Comparison is made with other reported chronic, recurrent, and persistent EBV syndromes, and tentative diagnostic criteria for chronic mononucleosis syndrome are presented. Recently available EBV serologic techniques allow for identification of patients who have reactivated EBV infection, and this reactivation may be related to symptoms.

Foreign bodies of the upper gastrointestinal tract: current management.

Abstract: The popularity of the flexible esophagogastroduodenoscope prompted us to reevaluate our management of foreign bodies. In this paper we report our experience and update treatment guidelines. In our series (from December 1975 to May 1982), 74 foreign bodies were removed: 12 with the rigid endoscope, 60 with the flexible endoscope, and two surgically. There was no morbidity or mortality. In the age group 1 to 10 years, there were 15 patients, while the age group 11 to 88 years had 59 patients. Although the rigid endoscope is less expensive and has a larger operating channel, the advantages of the flexible instrument are numerous. Foreign bodies of the pharynx and at the level of the cricopharyngeus muscle are best managed with a rigid endoscope; foreign bodies of the esophagus can be managed with rigid or flexible instruments, but are more easily managed with the latter. Foreign bodies of the stomach and duodenum that require removal can be managed only with the flexible panendoscope.

Colonization of Central Venous Catheters

Abstract: We studied etiologic factors important in colonization of 179 central venous catheters (CVCs) in patients randomized into group 1 (who received daily topical applications of povidone-iodine) or group 2 (who received only dry dressing changes). Colonization rates of CVC tips were similar between group 1 (18/84 or 21%) and group 2 (22/95 or 23%). Peripheral blood cultures grew Candida in eight hyperalimented patients (evenly divided between groups 1 and 2), S epidermidis in four other patients (also evenly divided), and gram-negative bacteria in three patients. Colonization rates for CVCs in place for 0 to seven days was 15.6% (17/109) and 76.7% (23/30) if used from eight to 30 days. Inflammatory signs at CVC sites were often absent when CVCs became colonized or produced bacteremia. Unimportant determinants of CVC colonization included skin securement of CVCs, antibiotic infusions through CVC lines, and masking and gowning of physicians before CVC placement. Daily applications of povidone-iodine did not reduce colonization of CVCs as compared to dry dressing changes.

The internship year: a study of sleep, mood states, and psychophysiologic parameters.

Abstract: Previous reports have suggested that first-year graduate physicians have a high incidence of psychologic distress and may show cognitive impairment as a result of sleep deprivation. We periodically evaluated 27 interns during their training year to determine amount of sleep, mood states, reaction time, critical flicker fusion, and symptoms of depression. We found the incidence of major depression in our subjects (four of 27) to be lower than previously reported but higher than expected for that age group in the general population. Risk factors for depression during the internship year were history of major depression, female sex, and unmarried status. The only significant change in average mood state was that anger progressively increased during the year. Subjects slept an average of 5.95 hours per 24-hour day during the year. Correlational analysis indicated that, contrary to predictions, performance on reaction time and critical flicker fusion improved with less sleep. At the end of the year, subjects regarded the year as stressful but not more so than had been anticipated.

Anaphylaxis in pregnancy

Abstract: The intrauterine anoxic insult to the fetus of a woman who suffered anaphylactic shock raises concern about supporting uteroplacental perfusion during maternal therapy. We propose ephedrine as an appropriate first-line medication.

Surgical procedures in patients aged 90 years and older.

Abstract: During the past five years 75 patients aged 90 years or more had 85 major surgical procedures at the Metropolitan Nashville General and Vanderbilt University hospitals. The most common operation was exploratory laparotomy. The second was lower extremity amputation for peripheral vascular disease and/or gangrene. Fifty-seven percent had general endotracheal anesthesia. Associated medical problems were common, and included congestive heart failure (24%), hypertension (21%), diabetes mellitus (13%), chronic arrhythmias (9%), history of myocardial infarction (8%), and history of cerebrovascular accident (5%). Eleven patients (13.4%), six of whom had general anesthesia, died after operation. Of these, two had postoperative pneumonia, two did not recover from bowel perforation and peritonitis, one had a postoperative myocardial infarction, another had a cerebrovascular accident, and one had sepsis. One patient's sudden death was likely due to myocardial infarction or pulmonary embolus. The other three deaths occurred in patients with extensive carcinomas (gallbladder carcinoma in one and widely metastatic carcinoma of unknown origin in two). These three patients died of the disease for which they were operated upon when the operation failed to alter its course. When surgical procedures are necessary to prolong and/or improve the quality of life in elderly patients, these procedures may be done in most cases with acceptable results.

Carcinoma of the hand: a 20-year experience.

Abstract: We reviewed our 20-year experience with cutaneous carcinoma of the hand and identified 70 cases (basal cell 23%, squamous cell 77%). The documented risk factors included solar radiation, trauma, and irradiation. Lesions were treated surgically with amputation, excision, skin graft, or flap closure, and nonsurgically with cryosurgery, curettage, 5-fluorouracil, or irradiation. The recurrence was lower with surgical treatment (3%) than with nonsurgical (33%). Regional lymphadenectomy was required in four patients for metastatic squamous cell carcinoma. Recurrence was greater (9%) and metastasis more common (38%) in patients with Marjolin's type of secondary squamous cell carcinoma than with solar-induced lesions. Cause is an important factor in outcome and should be considered in initial treatment and long-term management.

Clinical spectrum of pulmonary aspergillosis.

Abstract: Aspergillus produces diverse pulmonary manifestations, its clinical spectrum extending from harmless saprophytic colonization to universally lethal disseminated infection. Management of the conditions produced by Aspergillus is also diverse and may consist of either observation or treatment with corticosteroid agents or amphotericin B. The factors that influence the expression of Aspergillus into a specific clinical entity are not well understood, but are believed to be related to immune status, both pulmonary and systemic, and the genetic composition of the host.

Carcinoma of the cervical esophagus: diagnosis, management, and results

Abstract: Nine of 168 patients (5.3%) with carcinoma of the esophagus had primary tumors in the cervical esophagus. The principal symptoms and signs of carcinoma of the cervical esophagus were dysphagia, hoarseness, neck mass, and weight loss. The esophagogram was a very reliable study, revealing the abnormality in all nine patients. The true extent of the disease was better delineated by computerized tomography which demonstrated not only the intraluminal mass but also the extraesophageal spread. Endoscopic examination of the cervical esophagus was the definitive procedure to establish the diagnosis. All nine patients were treated with definitive radiotherapy, three surviving two to five years. The major cause of death was the failure to control local disease. 14 references, 3 tables.

Pulmonary edema due to obstructive sleep apnea.

Abstract: Many cardiorespiratory problems have been identified in patients with sleep apnea syndrome. Acute pulmonary edema as the primary feature of obstructive sleep apnea has recently been reported, and is thought to be caused by the effects of severe hypoxemia and/or extreme negative intrathoracic pressure. We have described another patient with sleep apnea syndrome who had pulmonary edema on at least three different occasions. Extremely high pulmonary artery pressure, paradoxic motion of the interventricular septum, and very low right heart ejection fraction were found. The paradoxic septal motion disappeared and the right heart ejection fraction increased after tracheostomy.

Acute myelogenous leukemia in pregnancy.

Abstract: The experience with acute myelogenous leukemia treated with newer chemotherapeutic agents during pregnancy is limited. We have reported the case of a mother treated during the 24th week of pregnancy, and her infant delivered in the 29th week. At 14 months the infant is of low height and weight, but has a normal head circumference and developmental parameters.

Predicting the outcome of hospitalization for elderly persons: home versus nursing home.

Abstract: Fifty elderly persons who had been admitted to an acute care hospital from Home and discharged to nursing homes were compared with 50 elderly persons who had been admitted to the same hospital from home and discharged to home during the same period. Discriminant function analyses were done t

Colonic Endometriosis: Its Clinical Spectrum

Abstract: SUMMARYWe have reviewed two cases of colonic enclometriosis. The first demonstrates the more frequently encountered symptoms of partial large-bowel obstruction. The second demonstrates the less frequently encountered cyclic rectal bleeding occurring at or near the time of menses. Conventional diagno

Opportunistic Scopulariopsis pneumonia in an immunocompromised host.

Abstract: We have described a patient with fatal Scopulariopsis pneumonia, a previously unreported infection, complicating immunosuppressive therapy for acute myeloblastic leukemia. This Scopulariopsis isolate was highly resistant to available antifungal agents, in part accounting for our patient's death.

Therapeutic value of hope.

Abstract: This paper discusses the therapeutic value of hope in the patient-caregiver relationship. Hope and hopelessness are viewed as a process involving the expectations of the patient and the caregiver. Hope must be realistic to be a positive factor in the healing process. While hope has therapeutic value, it also has limits. Caregivers need to be sensitive as to how their behavior can convey the hope or hopelessness of their patients' situation.

Systemic combination chemotherapy as primary treatment of brain metastasis from lung cancer.

Abstract: Five patients with primary lung cancer metastatic to the brain were treated with systemic combination therapy alone. One patient had had unsuccessful radiation therapy, while the other four received chemotherapy as the primary modality of treatment. Response was observed in all five patients. The concept of the blood-brain barrier and the role of systemic chemotherapy in metastatic cancer to the brain are discussed.

Safety of anterior cement fixation in the cervical spine: in vivo study of dog spine.

Abstract: There is increased use of methylmethacrylate in the treatment of neoplastic lesions of the spine. The advantage of this treatment is immediate stabilization, thus avoiding prolonged immobilization. In vivo study using a dog model showed that anterior fixation with cement, with or without Gelfoam as insulation material, produced no spinal cord injury.

Bowel obstruction due to infarcted splenosis.

Abstract: We have presented a case of splenosis (autotransplantation of splenic tissue) after traumatic rupture of the spleen, which produced bowel obstruction. Although rarely symptomatic, these splenic implants must be considered in the differential diagnosis of abdominal pain with or without intestinal obstruction in all postsplenectomy patients. When an incidental finding at exploratory celiotomy, these implants should be preserved as a means of retaining splenic function and preventing the complication of postsplenectomy sepsis.

Early onset anorexia nervosa.

Abstract: A review of records form Children's Memorial Hospital (Chicago) between 1960 and 1980 yielded 15 cases of anorexia nervosa in children aged 12 and under Three of these cases are described herein to point out the clinical characteristics and the possible connection to affective disorder (depression) of this variant of anorexia nervosa

Electrical stimulation in treatment of delayed union and nonunion of fractures and osteotomies.

Abstract: This study reviews the cases of 52 patients with 52 ununited fractures and osteotomies who were treated with two methods of electrical stimulation, one surgical, the other nonsurgical. Seventeen patients, 14 of whom had concomitant bone grafting, had implantation of a bone growth stimulator. There were three synovial pseudarthroses but no active infection in this group. The overall success rate in healing of the fractures was 82%. Thirty-five patients, of whom four had initial concomitant bone grafting, were treated with pulsing electromagnetic fields (PEMF). There were six draining infections but no pseudarthrosis in this group. Two nonunions healed after bone grafting was combined with PEMF treatment, when the latter alone had failed. Eighty-one percent of the fractures united, and drainage ceased in five of the six infections.

Campylobacter fetus ssp fetus cholecystitis and relapsing bacteremia in a patient with acquired immunodeficiency syndrome.

Abstract: Acute gangrenous cholecystitis and relapsing bacteremia caused by Campylobacter fetus ssp fetus occurred in a patient with acquired immunodeficiency syndrome. Biliary tract colonization probably accounted in part for this unusual phenomenon. Whether the patient's deficiency of cell-mediated immunity contributed to his disease is not known.

Hormones in the etiology and prevention of breast and endometrial cancer.

Abstract: Since the incidence of endometrial cancer among estrogen-treated women at Wilford Hall Air Force Medical Center was not increased as reported by others, a prospective study was begun in 1975. With this data base, the cases of breast and endometrial cancer in estrogen and oral contraceptive users were reviewed. The incidence of mammary malignancy in postmenopausal estrogen users (141.0:100,000) was lower than that of the untreated women, ie, nonhormone users (342.3:100,000) (P less than or equal to .01). The incidence of breast cancer in the estrogen-progestogen users (67.3:100,000) was significantly lower than that of the untreated women and than that expected from the Third National Cancer Survey (188.3:100,000) and the National Cancer Institute (NCI) data (229.2:100,000) (P less than or equal to .01). Oral contraceptives also decreased the risk of breast carcinoma, since the incidence in users (10.3:100,000) was significantly lower than expected in this age group according to both the Third National Cancer Survey (53.3:100,000) and the NCI data (57.3:100,000) (P less than or equal to .01). Unopposed estrogen replacement therapy increased the incidence of endometrial cancer to 410.8:100,000, but progestogen added to estrogen therapy significantly decreased this incidence to 68.1:100,000 (P less than or equal to .0001). The estrogen-progestogen users also had a significantly lower incidence of endometrial carcinoma than the untreated women (258.3:100,000) (P less than or equal to .005). Oral contraceptives, particularly the combination pill with estrogen and progestogen in each tablet, are protective against adenocarcinoma of the endometrium. The incidence of endometrial cancer apparently increased in premenopausal women during our study from 10.9:100,000 women in the first five years to 41.9:100,000 during the last two years as birth control pill use declined from 8,693 users in 1975 to 5,563 users during 1981, primarily in women over the age of 35.

Michigan alcoholism screening test to diagnose early alcoholism in a general practice

Abstract: General medical patients can be easily screened for alcohol dependence on a routine basis. The Michigan Alcoholism Screening Test (MAST) is a 24-item yes-no questionnaire concerning alcohol-related behavior. When it was included in the history self-administered to new patients in an internal medicine faculty-resident outpatient practice, it uncovered unsuspected alcohol dependence. The combined questionnaire (health history plus MAST) was given to 351 consecutive new outpatients. Thirteen (4%) were found to have positive MAST scores (greater than 7), indicating alcohol dependence. Nine patients were in the mild dependence range (7 to 20), two in the moderate range (20 to 30), and two in the severe range (30 to 53). All patients with significant MAST scores had complaints related to active drinking. The MAST score directed the physicians' therapeutic efforts in nine of 13 patients; in four the significant MAST score was ignored. The MAST is useful to detect unsuspected alcohol dependence in office practice. When used by faculty and residents trained in recognizing alcohol-related behavior, the test will properly direct therapeutic and rehabilitative efforts for those patients with the primary diagnosis of alcohol dependence.

Lithium intoxication associated with acute renal failure.

Abstract: Lithium can produce transient natriuresis, nephrogenic diabetes insipidus, and partial distal renal tubular acidosis. Lithium intoxication is commonly associated with mild renal insufficiency and may produce acute renal failure. We have described a case of acute renal failure in a patient with severe lithium intoxication, as well as cardiac arrhythmias and hypothyroidism, both of which have been reported to occur with lithium toxicity. Treatment with daily hemodialysis eventually produced complete recovery. Lithium clearance occurs quickly with hemodialysis, but a rebound effect occurs as lithium in intracellular water equilibrates with extracellular fluid. Prolonged dialysis may be required to reduce the blood lithium level to the therapeutic range. We conclude that lithium intoxication may produce severe reversible renal failure as a result of direct tubular epithelial damage.

Amphetamine-induced acute renal failure.

Abstract: A 32-year-old man had acute renal failure after ingesting amphetamines. The renal biopsy findings indicated acute interstitial nephritis. In contrast to other reports, which indicate an association between coexisting rhabdomyolysis, hyperpyrexia, or necrotizing angiitis and acute renal failure in amphetamine abusers, our case suggests that amphetamine alone may cause acute renal injury.

Radiologic examination of the small intestine: review of 402 cases and discussion of indications and methods.

Abstract: An analysis of the records of 300 patients who had had 370 small-bowel radiologic examinations and a subsequent 102 patients examined by fluoroscopy and enteroclysis suggests that enteroclysis (small-bowel enema) is extremely valuable in the radiologic evaluation of small intestinal disease. Our results suggest that best results are obtained if the radiologist spends adequate time to participate in and observe the studies carefully. We believe that the fluoroscopic observation of low-density barium passing through distended small bowel gives a much clearer picture of its status than routine follow-through examinations. Disagreement exists concerning the choice of Sellink's method, using dilute barium, and Herlinger's technique, using a somewhat denser barium followed by methylcellulose. We prefer the latter. Enteroclysis probably should not be done in the presence of a high small-bowel obstruction because of the danger of reflux and aspiration. If intubation is unsuccessful, an oral study should be postponed until the effects of the topical anesthesia disappear. A controlled prospective study of the accuracy of fluoroscopic enteroclysis versus a good detailed independent follow-through examination is needed.

Fulminant hepatic failure complicating metastatic breast carcinoma.

Abstract: A 27-year-old woman died in fulminant hepatic failure caused by metastatic carcinoma of the breast. At autopsy the liver looked grossly normal but was diffusely infiltrated by malignant tumor cells with resultant massive necrosis of liver parenchyma. Breast carcinoma has been the most common cause of this syndrome.

Tumors of the appendix: I. Neoplastic and nonneoplastic mucoceles.

Abstract: We reviewed the clinical data and pathologic material on 46 patients with lesions originally interpreted as appendiceal mucocele or mucinous adenocarcinoma from two medical centers. The mucoceles, characterized by accumulation of mucus in a dilated lumen, could be divided into three distinct entities: nonneoplastic retention mucoceles (eight cases), cystadenomas (26 cases), and cystadenocarcinomas (eight cases). There were four mucinous adenocarcinomas. Retention mucoceles are associated with little morbidity and are cured by appendectomy. Cystadenomas and cystadenocarcinomas mimic the behavior of ovarian neoplasms of borderline malignant potential. Some of these lesions were associated with pseudomyxoma peritonei, but did not have systemic metastases. Mucinous adenocarcinomas without mucocele mimic the behavior of ordinary large bowel carcinoma.

Pancreatitis induced by intravenous infusion of a fat emulsion in an alcoholic patient.

Abstract: We report an alcoholic patient with acute relapsing pancreatitis in whom the intravenous infusion of a fat emulsion precipitated a bout of acute pancreatitis. The various relationships between pancreatitis, alcoholism, and hyperlipemia are not clear, and guidelines for the use of intravenous fat emulsions in patients with pancreatitis should take into account their complex interrelationship.

Elastofibroma arising in the foot.

Abstract: Elastofibroma is a nonneoplastic proliferation of collagen and abnormal elastic fibers, with a marked predilection for the subscapular area. We have described an elastofibroma occurring in a previously unreported location, the plantar surface of the foot. Trauma has been implicated in the pathogenesis of these lesions, regardless of site, and our patient's history of intensive dance and aerobic exercise further supports this relationship. Although elastofibromas are rare, they may be considered in the differential diagnosis of fibrous lesions arising at sites of repetitive strenuous exercise or injury.