Showing papers in "Southern Medical Journal in 1985"
TL;DR: It is confirmed that Cheyne-Stokes breathing predicts an adverse short-term mortality rate in patients with left ventricular heart failure, and this finding confirms the clinical impression thatCheyne- Stokes breathing is a poor prognostic sign in LVF.
Abstract: Fifteen patients with left ventricular heart failure (LVF) without known breathing disorders during sleep had full-night recordings of sleep and breathing to study the incidence and impact of the apnea of Cheyne-Stokes breathing. This group showed a marked degree of sleep-related breathing abnormalities, 40% demonstrating Cheyne-Stokes breathing with five or more central apneas per hour of sleep. Cheyne-Stokes breathing during sleep in patients with LVF predicted an increased short-term mortality rate. All six patients with LVF and Cheyne-Stokes breathing with more than five apneas per hour of sleep were dead within six months, while only three of nine patients without recurrent apnea died within six months, a significant difference (P less than .05) even in this small group. Among seven patients with LVF studied with the polysomnogram, there were statistically significant differences between the Cheyne-Stokes and non-apnea groups in total sleep time, awakening per hour, and the number of arterial desaturations. Although sleep disturbances have been anecdotally described in patients with LVF, no previous investigation has determined the incidence and impact of Cheyne-Stokes breathing during sleep in LVF. Our findings that Cheyne-Stokes breathing predicts an adverse short-term mortality rate confirm the clinical impression that Cheyne-Stokes breathing is a poor prognostic sign in LVF.
161Â citations
TL;DR: This study of 533 vascular access sites for long-term hemodialysis in patients with end-stage renal disease, accumulating more than 12,000 patient months, indicated that primary arteriovenous fistula (AVF) is the procedure of choice.
Abstract: This study of 533 vascular access sites for long-term hemodialysis in patients with end-stage renal disease, accumulating more than 12,000 patient months, indicated that primary arteriovenous fistula (AVF) is the procedure of choice. The group receiving primary AVF had the greatest duration of patency: 84% at three years compared to 70% for the group receiving polytetrafluoroethylene (PTFE) grafts and less than 50% for those receiving bovine carotid artery heterografts (BCAH). Furthermore, the primary AVF group had fewer complications (25 complications in 273 fistulas) than either the BCAH group (61 in 58 grafts) or the PTFE group (171 in 202 grafts). No complication resulted in death in the primary AVF group, but seven deaths resulted from complications of the access in the graft groups, further solidifying the position of the primary AVF as the procedure of choice for chronic hemodialysis access.
118Â citations
TL;DR: Examination of health beliefs of 93 male diabetic patients correlated their beliefs with behavioral and physiologic measures of compliance and suggested that improving attitudes about care may be a means of directly influencing control of the disease.
Abstract: The problem of compliance and control in the treatment of diabetic patients is widely recognized. However, compliance research is contradictory and impractical as a basis for intervention to improve the patient's adherence to his medical regimen. Health beliefs may provide an opportunity to intervene to improve compliance and control of the disease. In this study we examined the health beliefs of 93 male diabetic patients and correlated their beliefs with behavioral and physiologic measures of compliance gathered at a follow-up interview. The belief in severity of illness related to compliance. Health beliefs were better predictors of metabolic control than compliance itself. The study suggests that improving attitudes about care may be a means of directly influencing control of the disease.
107Â citations
TL;DR: Endoscopically evaluated the bypassed segments in 51 patients three to 24 months after a standard gastric bypass procedure, finding that there was significantly more gastritis by endoscopic grading in the distal bypassed segment than in the proximal part of the stomach.
Abstract: Surgical measures for the treatment of morbid obesity include gastric bypass of the stomach and duodenum. We endoscopically evaluated the bypassed segments in 51 patients three to 24 months after a standard gastric bypass procedure. Retrograde endoscopy was successful in 33 of the patients (65%). There was significantly more gastritis by endoscopic grading in the distal bypassed segment than in the proximal part of the stomach. The gastritis in the bypassed segment was associated with pooled bile in 97% of the patients. The severity of gastritis did not appear to be related to the time after surgery and was as severe three months after surgery as it was at 24 months. Histologically, the gastritis was nonconfluent, and often the histologic and endoscopic findings were at variance. There was intestinal metaplasia in biopsy specimens from the distal pouch in four of the 33 patients. The mechanism for the high incidence of gastritis is unknown, but may be related to decreased antral motility due to distention of the proximal pouch with food. These patients require close observation for changes in the bypassed segment of stomach that may occur as a consequence of chronic inflammation.
75Â citations
TL;DR: The results indicate that patients with primary esophageal motor disorders have a good clinical response to nifedipine therapy, and improvement was most marked in patients with hypertensive lower esphageal sphincter.
Abstract: The effect of nifedipine on esophageal symptoms was evaluated in 20 patients with primary esophageal motor disorders. The patients were randomized to receive nifedipine (10 mg t.i.d.) or placebo for two weeks, and then crossed over to receive the other medication. Ten patients had hypertensive lower esophageal sphincter, four had diffuse esophageal spasm, three had vigorous achalasia, two had "nutcracker esophagus," and one patient had achalasia. The score of chest pain or dysphagia was recorded on a scale of 0 to 10 during each study. The patients who received nifedipine improved significantly compared to those who received placebo. This improvement was most marked in patients with hypertensive lower esophageal sphincter. No significant side effects or changes in blood pressure were encountered in any of the study groups. Our results indicate that patients with primary esophageal motor disorders have a good clinical response to nifedipine therapy.
62Â citations
TL;DR: A high WBC with malignancy is a late phenomenon, usually occurring shortly before death, and does not correlate with any pathologic findings such as necrosis, white cell infiltration of the tumor, or specific inflammatory changes.
Abstract: Twenty-one patients with malignancy had a peripheral white blood cell count of 50,000/cu mm or more. The malignancies arose from several tissues, especially lung; all were carcinomas except for one osteogenic sarcoma. In no case was there evidence of leukemia as defined by disorderly marrow growth, abnormal chromosomes, or abnormal leukocyte alkaline phosphatase levels. The peripheral blood of these patients showed segmented neutrophils, bands, and occasional metamyelocytes. When young cells such as myelocytes were seen, they did not persist. A high WBC with malignancy is a late phenomenon, usually occurring shortly before death, and does not correlate with any pathologic findings such as necrosis, white cell infiltration of the tumor, or specific inflammatory changes. most of the associated tumors are of giant cell size, but serum showed no evidence of colony stimulating activity. This was true of two tumors reported in the literature, yet the tumors could be shown in vitro to produce colony stimulating activity. The tumor probably does produce some type of granulocytopoietin, but methods for detecting it are presently limited.
57Â citations
Journal Article•
TL;DR: Tremor was suppressed by alcohol ingestion in all patients and with whisper in two, and three patients responded to treatment with propranolol (Inderal), and one did well with voice training.
Abstract: We evaluated four patients with an initial and predominant voice tremor. All were referred for evaluation for suspected parkinsonism, though vocal tremor was the only symptom. These three women and one man ranged in age from 37 to 59 years. Neurologic evaluation and laryngeal examination were unremarkable. No signs of parkinsonism were present. All patients had a family history of tremor, though in only one family was vocal tremor the sole manifestation. Tremor was suppressed by alcohol ingestion in all patients and with whisper in two. Duration of tremor before evaluation ranged from eight months to six years. Visual representation of tremor was obtained in three, with frequencies ranging from 4 to 10 cps. Three patients responded to treatment with propranolol (Inderal), and one did well with voice training. Follow-up was six months to ten years. Although previous cases of essential vocal tremor with concurrent tremor elsewhere have been noted, only six cases of isolated voice tremor had been reported and response to therapy was not mentioned. Essential tremor may also be isolated to the head, chin, and hands.
57Â citations
TL;DR: Two episodes of hepatic dysfunction associated with oral cyclophosphamide administration in patients with systemic rheumatic diseases are reported.
Abstract: Cyclophosphamide, a potent alkylating agent, is effective therapy for some rheumatic diseases. Despite primary hepatic activation of the drug, hepatic toxicity has been reported only in one case. We have reported two episodes of hepatic dysfunction associated with oral cyclophosphamide administration in patients with systemic rheumatic diseases.
55Â citations
TL;DR: When 113 patients who had had nasal surgery for chronic obstruction were questioned about their snoring habits before and after operation, 42% said they had snored before nasal surgery and 77% had either elimination or improvement of snoring after nasal surgery.
Abstract: When 113 patients who had had nasal surgery for chronic obstruction were questioned about their snoring habits before and after operation, 42% said they had snored before nasal surgery. Of that group, 77% had either elimination or improvement of snoring after nasal surgery. Nasal obstruction is one
53Â citations
TL;DR: This case stresses the possibility of herpes simplex encephalitis in patients with an acute mental change with a history of a schizo-affective disorder.
Abstract: We have reported an unusual presentation of herpes simplex encephalitis in a patient with a 3 1/2-year history of a schizo-affective disorder. In the month immediately before diagnosis, the patient lost contact with reality and became violent. After successful treatment with antipsychotic medication, he had agitation and disorientation, as well as fever and cerebrospinal fluid pleocytosis. There were no focal neurologic findings. When a low-density lesion in the right temporal lobe was defined by computerized axial tomography, brain biopsy and culture isolated herpes simplex virus type 1. After therapy with vidarabine, the patient regained independence in simple daily activities. This case stresses the possibility of herpes simplex encephalitis in patients with an acute mental change.
43Â citations
TL;DR: Treatment of Aspergillus sinusitis principally involves surgical debridement, reestablishment of aeration and drainage of the involved sinuses, and adjunctive antifungal chemotherapy.
Abstract: SUMMARYAspergillus infection of the paranasal sinuses is rare but is the most common fungal infection of these structures and should be suspected when sinusitis does not respond to antibacterial drugs. Our case involved the sphenoid sinus, and was initially thought to be a nonfunctioning pituitary t
Journal Article•
TL;DR: Patients with stage A and B disease are best treated with preoperative radiation therapy followed by Craniofacial resection, and patients with stage C disease are treated with cyclophosphamide and vincristine before irradiation and craniof facial resection.
Abstract: Esthesioneuroblastoma is an uncommon nasal tumor originating from cells of neural crest origin. An increased awareness of this neoplasm by clinicians and pathologists has led to an increase in its diagnosis. In the Department of Otolaryngology--Head and Neck Surgery at the University of Virginia Medical Center, 22 cases have been treated. A review of the biologic course of these cases has allowed us to make certain recommendations for therapy. Patients with stage A and B disease are best treated with preoperative radiation therapy followed by craniofacial resection. Patients with stage C disease are treated with cyclophosphamide and vincristine before irradiation and craniofacial resection. If a significant response occurs these patients receive postoperative chemotherapy. We believe this treatment should result in five-year survivals in excess of 50%.
TL;DR: A case of bilateral simultaneous spontaneous quadriceps tendon rupture, established by clinical examination, which involves surgical repair followed by cylinder cast application for six to eight weeks.
Abstract: We have described a case of bilateral simultaneous spontaneous quadriceps tendon rupture. The diagnosis is established by clinical examination. Definitive treatment consists of surgical repair followed by cylinder cast application for six to eight weeks.
Journal Article•
TL;DR: It is recommended that a comprehensive approach to CPR be adopted by all hospitals, involving education regarding appropriate patient selection, assurance of skilled application and backup care for survivors, and a mechanism for routinely monitoring outcome.
Abstract: Since the introduction of cardiopulmonary resuscitation (CPR) 25 years ago, there have been many advances in cardiopulmonary technology and in our understanding of the factors leading to a successful outcome. Despite these advances, our study of outcomes in 88 patients having CPR at Johns Ho
TL;DR: Delusions of parasitosis, or a patient's persistent belief that he has cutaneous invasion by parasites despite medical evidence to the contrary, is an uncommon syndrome associated with a wide variety of medical and psychiatric disorders.
Abstract: Delusions of parasitosis, or a patient's persistent belief that he has cutaneous invasion by parasites despite medical evidence to the contrary, is an uncommon syndrome associated with a wide variety of medical and psychiatric disorders. Its prognosis has been improved considerably by the introduction of pimozide, a potent neuroleptic agent.
TL;DR: Ten patients with sickle cell anemia who became acutely ill within a few days after a blood transfusion are described and efforts to more closely match recipient and donor red cell antigens are suggested.
Abstract: We describe ten patients with sickle cell anemia who became acutely ill within a few days after a blood transfusion. Two patients died. In eight cases the posttransfusion detection of alloantibodies suggested that delayed hemolytic reactions to transfusion were involved in precipitating the acute illness. In some cases the illnesses mimicked vaso-occlusive crises, with bone marrow infarction, while in other cases transient biliary obstruction or transient renal insufficiency was documented. Profound anemia mimicked aplastic crises, but we observed a remarkable capacity of the bone marrow to restore the hemoglobin level without further transfusion. In view of the prevalence of delayed hemolytic transfusion reactions in these patients receiving frequent transfusions and whose red cell antigens differ from those of the white population, we suggest that efforts to more closely match recipient and donor red cell antigens would be clinically, technically, and financially advantageous. Moreover, criteria for transfusion in sickle cell anemia should be strictly scrutinized. Quantitation of transfused hemoglobin A has proved useful in confirming delayed hemolytic reactions in sickle cell disease.
TL;DR: The clinical and laboratory characteristics of 34 patients who had classical heatstroke during the Kansas City heat wave of 1980 were reviewed, with patients with coma, temperature greater than or equal to 108 F (42.2 C), severe hypotension, coagulopathy, and need for respiratory assistance were at highest risk of death.
Abstract: We reviewed the clinical and laboratory characteristics of 34 patients who had classical heatstroke during the Kansas City heat wave of 1980. The patients were elderly, predominantly black, and of low socioeconomic class. Overall mortality was 18%, with 9% of patients exhibiting severe residual neurologic deficit; 73% had full recovery. Patients with coma, temperature greater than or equal to 108 F (42.2 C), severe hypotension, coagulopathy, and need for respiratory assistance were at highest risk of death. Associated disease was common (67%), with hypertension (32%), diabetes (21%), and alcoholism (21%) being most frequent. Medications known to predispose to heatstroke were used by 56% of patients. Hematologic abnormalities were nonspecific, and clinical evidence of renal or hepatic failure was rare. Hyponatremia, hypokalemia, hypocalcemia, hypomagnesemia, hypophosphatemia, and elevated levels of creatine phosphokinase and glucose were frequent but did not correlate with outcome. The predominant arterial blood gas abnormality was metabolic acidosis or a combined metabolic acidosis and respiratory alkalosis.
TL;DR: The patient reported herein had biopsy-proven pulmonary vasculitis on two occasions, associated with flares in ulcerative colitis, and Corticosteroid therapy appears to be a rational first step in the management of this condition.
Abstract: Pulmonary vasculitis is an infrequent complication of ulcerative colitis. The patient reported herein had biopsy-proven pulmonary vasculitis on two occasions, associated with flares in ulcerative colitis. The diagnosis of this entity is best made by open lung biopsy. Corticosteroid therapy appears to be a rational first step in the management of this condition.
TL;DR: Physicians in training in the medical center were found to have a higher risk of tuberculous infection than other hospital employees and their compliance rate to annual tuberculin testing and chemoprophylaxis is less than 50%.
Abstract: Physicians in training in our medical center were found to have a higher risk of tuberculous infection than other hospital employees. Their annual tuberculin conversion rate was 3.96%; in two of the 15 recent converters, active disease developed. There is a significant linear relationship between the acquisition of tuberculous infection and the duration of training in an urban teaching hospital. Their compliance rate to annual tuberculin testing and chemoprophylaxis is less than 50%.
TL;DR: A review of 15 cases of carotid artery exposure or rupture in patients with no recurrent tumor demonstrated several important principles, reaffirms the importance of irradiation and orocutaneous fistula as risk factors, and reiterates the need for prophylaxis and treatment ofcarotid exposure and treatment.
Abstract: Review of 15 cases of carotid artery exposure or rupture in patients with no recurrent tumor demonstrated several important principles. Irradiation was a risk factor in 90% of cases of carotid blowout. Only one of five patients (20%) with carotid exposure who had not had irradiation had carotid perforation. Immediate death occurred in two of 15 (13%), and delayed death in five of 15 (33%). The neck wound was successfully controlled in 11 of 15 cases, requiring extracervical vascularized muscle or skin in eight of the 11 cases. Only one of seven pectoralis major flaps failed to control infection in the neck. This review reaffirms the importance of irradiation and orocutaneous fistula as risk factors. A rationale for prophylaxis, treatment of carotid exposure, and treatment of carotid rupture is presented.
TL;DR: The persistent and recurrent pyodermas in four patients indicate that brown recluse spider bites may not be self-limited but induce PG or PG-like lesions; arthropod bites in general may induce PG in susceptible people; and treatment of the PG- like lesions in these patients may be difficult.
Abstract: Brown recluse spider bites are usually self-limited skin lesions that infrequently progress to bullae, ulceration, and scarring. We treated a patient with a documented brown recluse bite who had recurring lesions resembling pyoderma gangrenosum (PG) that persisted for months. Three other patients referred to Vanderbilt University because of probable brown recluse bite also had pyoderma for the first time after a suspected arthropod bite. The persistent and recurrent pyodermas in these four patients indicate that (1) brown recluse spider bites may not be self-limited but induce PG or PG-like lesions; (2) arthropod bites in general may induce PG in susceptible people; and (3) treatment of the PG-like lesions in these patients may be difficult.
TL;DR: A retrospective review of the charts of patients receiving radiation therapy for brain metastasis revealed that one third presented neurologic symptoms without prior diagnosis of cancer.
Abstract: A retrospective review of the charts of patients receiving radiation therapy for brain metastasis revealed that one third presented neurologic symptoms without prior diagnosis of cancer Lung cancer was detected in two thirds of this group, and in one third, the primary site remained unknown There was good clinical and CT correlation CT scans with and without contrast injection were evaluated in the study 6 references, 4 tables
TL;DR: When treating injured patients, it is important to recall that many older adults living in rural areas are not adequately immunized against tetanus, and such patients should receive human tetanus immunoglobulin, as well as tetanus toxoid.
Abstract: Three cases of tetanus occurring in a community in southern West Virginia in five years prompted a survey of the immunization status of the population of this region. An immunization history was obtained from 540 consecutive patients seen at three different health care facilities. Of these, 386 (71.5%) had received prior tetanus protection, 65 (12%) had never been immunized, and 89 (16.5%) were uncertain or had received incomplete immunization. Of the 65 nonimmunized patients, 54 (83%) were older than 50 and only 11 (17%) were younger. Compared to the total group sampled, significantly more nonimmunized patients (both male and female) were older than 50 (P less than .001). Also, significantly more of these never immunized individuals lived in rural areas (P less than .001). In a group of 222 patients identified as being at increased risk of having tetanus, 65 (29%) had never been immunized, 89 (40%) were of uncertain or incomplete status, and 68 (30.5%) had been immunized more than ten years previously. One hundred twenty (54%) high-risk patients were older than 50 and 103 (46%) were younger. Compared to the entire population sampled, high-risk patients included significantly more who were older than 50 (P less than .001). Also, significantly more high-risk patients lived in rural areas (P less than .007). When treating injured patients, it is important to recall that many older adults living in rural areas are not adequately immunized against tetanus. Such patients should receive human tetanus immunoglobulin, as well as tetanus toxoid.
TL;DR: In this paper, the authors studied 25 patients who had lower extremity amputation for neoplasia and found phantom limb pain in cancer patients similar in presentation and description to that in noncancer amputees.
Abstract: Phantom sensation and phantom limb pain are two recognized sequelae of limb amputation. In most previous surveys, amputations were done for arteriosclerotic or trauma related conditions. We studied 25 patients who had lower extremity amputation for neoplasia. In studying the features of pain before and after amputation, we found phantom limb pain in cancer patients similar in presentation and description to that in noncancer amputees. There appeared to be no correlation between the severity of each episode of phantom pain and the overall effect of the pain on the patient's life. The quality and location of the phantom pain did not resemble the preamputation pain. We recommend a multidisciplinary approach to treatment.
TL;DR: Four cases that cover the spectrum of abnormalities of intracranial tuberculosis shown by CT are presented that can heighten the index of suspicion for what is often an overlooked diagnosis and can lead to earlier treatment, with decreased morbidity and mortality.
Abstract: Intracranial tuberculosis is often insidious, may be difficult to diagnose clinically, and is neurologically devastating if untreated. The advent of computerized tomography has permitted earlier detection of the structural abnormalities associated with intracranial tuberculosis than was possible with older techniques. Correct radiologic interpretation can heighten the index of suspicion for what is often an overlooked diagnosis and can lead to earlier treatment, with decreased morbidity and mortality. We present four cases that cover the spectrum of abnormalities of intracranial tuberculosis shown by CT.
TL;DR: It is concluded that although biliary surgery in cirrhotic patients carries a high mortality, this risk can be assessed preoperatively and there appears to be a small subgroup of patients with cirrhosis and cholelithiasis who can have a favorable outcome.
Abstract: :Operations on the biliary tract in cirrhotic patients are reported to have a higher than normal risk of operative morbidity and mortality. We reviewed 39 cases from two university-based hospitals over a five-year period. Each patient had biliary tract surgery and biopsy-proven cirrhosis. Ei
TL;DR: Among the nine cases diagnosed, roentgenographic evidence of pulmonary tuberculosis and positive PPD test were found to be highly suggestive diagnostic clues and computerized tomography of the spine was a useful way of determining the extent of the disease and following response to therapy.
Abstract: Although the incidence of tuberculosis is decreasing, spinal tuberculosis is still an important disease. Delay in diagnosis and treatment results in long-term disability. We reviewed our cases of spinal tuberculosis diagnosed between 1975 and 1982, with special reference to those features that permit early diagnosis. Among the nine cases diagnosed, roentgenographic evidence of pulmonary tuberculosis (7/9) and positive PPD test (8/8) were found to be highly suggestive diagnostic clues. Computerized tomography (CT) of the spine was a useful way of determining the extent of the disease and following response to therapy. Various modes of therapy were used, and the outcome was related to the extent of the disease and duration of symptoms before initiation of therapy. In early stages, medical therapy alone is adequate; surgical intervention is necessary in cases with neurologic features.
TL;DR: After evaluating patient tolerance, quality of colonic cleansing, and changes in microflora and colonic gas, GoLYTELY was found to be safe, rapid, and effective and may become the preferred method of bowel cleansing.
Abstract: We reviewed our experience with an oral gut lavage solution (GoLYTELY), used as a rapid bowel cleansing preparation, and the prospective clinical trials reported in the literature to compare the overall experience with this type of preparation for colonoscopy and colon surgery. Five studies (546 patients) compared GoLYTELY to standard preparations for colonoscopy, while three trials (177 patients) have studied surgical patients. After evaluating patient tolerance, quality of colonic cleansing, and changes in microflora and colonic gas, GoLYTELY was found to be safe, rapid, and effective. It is well tolerated by patients and may become the preferred method of bowel cleansing.
TL;DR: A surgical technique for ligating the ovarian arteries is presented, believing that teaching both bilateral hypogastric arteries ligation and ovarian artery ligation should be an integral part of obstetric and gynecologic training.
Abstract: Hypogastric artery ligation and internal iliac artery ligation are the same procedure. It has been several years since extensive work on this procedure has been reported in the literature. Since this has proved to be a potentially life-saving technique in serious obstetric and pelvic hemorrhage, it is somewhat surprising to find that the procedure is poorly understood. We have reviewed this procedure in depth, emphasizing important aspects and restating indications for its use. We have also included a case presentation in which we recently performed bilateral ligation of the hypogastric arteries and the ovarian arteries to control intractable hemorrhage. Although ovarian artery ligation is often mentioned as an adjunct in controlling pelvic hemorrhage, we believe the technique has never been described in the English language. We present a surgical technique for ligating the ovarian arteries, believing that teaching both bilateral hypogastric artery ligation and ovarian artery ligation should be an integral part of obstetric and gynecologic training.
TL;DR: The conceptual evolution of learning style analysis, especially its use in the health professions, is reviewed, and the Kolb Learning Style Inventory (LSI) is described, which is used to study 205 anesthesia personnel.
Abstract: Analysis of learning style, a relatively new technique in the field of education, is being used in grade school and college, as well as in graduate and postgraduate training programs. The trend in the health professions to emphasize continuing education has created a need for individual practitioners to understand the principles of self-education. Analysis of learning style is useful in this regard. It also provides a basis for teaching task-specific cognitive skills to those in residency training. In this article we review the conceptual evolution of learning style analysis, especially its use in the health professions, and describe the Kolb Learning Style Inventory (LSI), which we use to study 205 anesthesia personnel.