Showing papers in "Southern Medical Journal in 1991"

Long-term medical consequences of incest rape and molestation.

Abstract: One hundred thirty-one patients who gave a history of childhood sexual abuse were seen in a general medical practice decades after the event and were compared with a control group. The subject patients were found to be distinct for chronic depression, morbid obesity, marital instability, high utilization of medical care, and certain psychosomatic symptoms, particularly chronic gastrointestinal distress and recurrent headaches. It is clear that these remote events can underlie difficult chronic medical problems. Questions about childhood sexual abuse must become part of the practitioner's review of systems in these difficult cases, if not routinely.

Patient reading ability: an overlooked problem in health care.

Abstract: Health care workers often assume that patients who have completed a certain grade in school can read at that level. This study examines the relationships between patient reading ability, the last grade completed, and the reading ability necessary to comprehend commonly used written materials. We tested 528 patients during regular visits to seven outpatient clinics serving a predominantly indigent population. In addition, we analyzed the readability of 280 brochures and consent forms used in these clinics. Most patients had reading abilities on a level far below their last grade completed, while almost all materials tested were written on a level far above average patient reading ability. We conclude that patient reading ability should be routinely tested and that written materials should be developed on a level commensurate with patient reading ability.

Diet, behavior modification, and exercise: a review of obesity treatments from a long-term perspective.

Abstract: Reviewed herein are the long-term weight loss outcomes of three fairly recent major modifications of standard dietary therapy for obesity Appraised separately and in combination, these therapeutic approaches are very low calorie diets (VLCD), behavior modification, and exercise The weight loss results from VLCD are impressive for only the first 6 to 10 months Adding behavioral procedures to VLCD increases the weight loss for the first year or two, but not in 3 to 5 years Adding exercise further increases the weight loss at 1 to 2 years, and those who continue regular exercise achieve the best weight loss results 1 to 6 years later

The diabetic foot: consequences of delayed treatment and referral.

Abstract: The pathophysiology of foot problems in diabetic patients is poorly understood by many physicians. Two major factors that frequently lead to a delay in appropriate treatment with subsequent limb loss are failure to appreciate the presence and severity of underlying infection and attribution of gangrene of the toe and forefoot to microvascular disease. To evaluate the consequences of delayed recognition and treatment, we reviewed the records of 55 diabetic patients with localized gangrene or infection of the forefoot in 62 limbs, treated consecutively on a single vascular surgical service over a 2-year period using a standard protocol. All appropriately treated neuropathic ulcers and forefoot infections healed in patients with palpable pedal pulses. If foot pulses were absent and arteriography confirmed large-vessel occlusive disease, foot lesions and infections likewise healed if concomitant revascularization was done. In our series, 33 bypasses were required because of severe atherosclerotic occlusive disease. Only one patient had "unreconstructable" arterial disease. Limb salvage was 86% at a mean follow-up of 12.4 months. In 16 of the patients (29%), there was a prolonged delay between initial treatment and referral for definitive care. The specific causes of delay were underestimation of the severity of foot infection in 10 patients, and lack of recognition of ischemia due to large-vessel occlusive disease in six. These delays led to more proximal levels of amputation in six patients, including three below-knee amputations in patients with limbs that were initially salvageable.

Continuous intravenous infusion of morphine for severe dyspnea.

Abstract: We describe eight patients who had terminal lung cancer causing severe dyspnea unrelieved by oxygen, nonnarcotic drugs, or intermittent bolus narcotics. We treated these patients with continuous intravenous infusion of morphine, beginning with bolus IV injections of 1 or 2 mg of morphine every 5 to 10 minutes until the patient reported relief. A continuous morphine infusion was then started, with the hourly dose equal to 50% of the cumulative bolus dose. Vital signs, degree of sedation, and blood gases were serially followed. Six patients achieved good dyspnea relief, one had moderate relief, and one had a poor response. Variable changes were noted in the PaO2, whereas PaCO2 steadily increased in five of seven patients, and pH decreased in six. There was little change in systolic blood pressure or pulse, and only one individual had less than 10 respirations per minute. The major side effect of treatment was sedation, treated by temporarily discontinuing morphine until the patients' mental status improved and then restarting the infusion at a 50% lower hourly morphine dose. Mean time of study was 30 hours (range 16 to 87 hours). Seven of the eight study patients died during treatment. Whether morphine therapy shortened survival is uncertain. We conclude that continuous morphine infusion is effective therapy for severe dyspnea. The treatment is ethically justified. Relief of suffering is the primary goal of therapy, and less risky treatments are unavailable.

Titrated intravenous barbiturates in the control of symptoms in patients with terminal cancer.

Abstract: Patients with terminal cancer may have a series of severe and dehumanizing physical and psychologic symptoms. To improve symptom control in the final days and hours of life, we administer intravenous barbiturates continuously to provide heavy sedation or continuous somnolence. Titrated dosage is then reduced to a minimum, after a desired steady-state has been achieved. Improved symptom control is provided, and the patient's dignity is maintained until death.

Transdermal clonidine versus chlordiazepoxide in alcohol withdrawal : a randomized, controlled clinical trial

Abstract: In a prospective, double-blind comparison, we assessed the efficacy of transdermal clonidine with that of chlordiazepoxide in the treatment of moderately severe acute alcohol withdrawal syndrome. While having significant withdrawal symptoms, 50 hospitalized men were randomly assigned to receive either transdermal clonidine or chlordiazepoxide over a 4-day study period. Outcome was evaluated daily, medically and psychiatrically, using both objective and subjective measurements for dependent variables. No patient in either study group had seizures or progression to delirium tremens. The group receiving transdermal clonidine had a more significant response globally for the signs and symptoms of alcohol withdrawal, as measured by the Alcohol Withdrawal Assessment Scale. Also, clonidine more effectively lowered elevated systolic and diastolic blood pressure and heart rate. The core target symptom, anxiety, decreased significantly more in the patients receiving transdermal clonidine when measured by the Hamilton Anxiety Rating Scale and its subscale for somatic anxiety. Cognitive function responded equally in both study populations. Clonidine-treated patients reported less diarrhea, dizziness, headache and fatigue, and the chlordiazepoxide-treated patients reported less nausea and vomiting. We conclude that transdermal clonidine is effective treatment for the acute alcohol withdrawal syndrome.

The efficacy of palliative and definitive percutaneous versus surgical drainage of pancreatic abscesses and pseudocysts: a prospective study of 85 patients.

Abstract: We compared the efficacy of percutaneous to surgical drainage in a prospective study in 85 patients with pancreatic abscesses and pseudocysts. Percutaneous drainage of pancreatic abscesses in 18 patients cured three and palliated 12 who were eventually cured by elective surgical ablation; three patients died. This compares well to our 15 surgical patients, of whom four were cured by surgery alone and six were palliated. All were subsequently cured by additional computerized tomography-guided or ultrasound-guided percutaneous drainage and medical management or surgery. Five of the 15 died. Percutaneous drainage cured 11 of 14 infected pseudocysts and palliated two, which were subsequently cured by surgery; one was palliated but the patient was lost to follow-up. Surgical drainage cured six of 12 infected pseudocysts and palliated the other six, of which four were cured by further surgery and the other two were cured by secondary percutaneous drainage. Nine of 12 noninfected pseudocysts were cured by percutaneous aspiration, and two were palliated and later cured. In one patient, disease progressed, and he was ultimately lost to follow-up. Thirteen of 14 noninfected pseudocysts were cured by surgical drainage. The other patient died of pulmonary embolus. In patients treated by percutaneous techniques, there were four major complications. Our study established distinct advantages of percutaneous drainage under computerized tomographic and ultrasonic guidance: (1) the procedures can be carried out under ultrasonic guidance in an intensive care unit on critically ill patients, (2) the technique proved highly effective for initial palliation, with defervescence and stabilization occurring in most critically ill patients within 48 hours, (3) findings from fine needle aspiration provided valuable information as to microorganisms and antibiotic sensitivities and differed in 29 of 85 patients from those of concomitant blood cultures, and (4) definitive eradication of the process (surgical ablation of residual necrotic material) can be elected after the patient's clinical condition stabilizes.

Obstetric complications in young teenagers.

Abstract: We compared pregnancy outcome in 286 teenaged primigravidas (516 years old) and 267 adult primigravidas (21 to 25 years old) who had similar prenatal care, socioeconomic status, and racial balance. The incidence of preterm labor and delivery of a low birthweight infant was significantly high

Colorectal cancer: current trends in initial clinical manifestations.

Abstract: Colorectal carcinoma (CRC) is a common cause of cancer morbidity and mortality in the United States. There continues to be controversy regarding the effectiveness and feasibility of various screening programs for CRC. To determine how cases of CRC are currently detected, we reviewed a series of 246 consecutive patients with well-documented pathologic staging and clinical presentation. Patients with low stage CRC (0 or A) had smaller tumors, were less likely to be anemic at presentation, and were more likely to have tumors located in the left side of the colon than patients with tumors at stage B or higher. Thirty-two of the 246 tumors were detected in asymptomatic patients through screening. These tumors were more likely to be of a lower stage than those in patients with active gastrointestinal symptoms. In our experience active screening programs detect a relatively small number of CRCs. A majority (66%) of CRCs are still detected from symptoms referable to the gastrointestinal tract.

Enterobacter sakazakii bacteremia in an adult.

Abstract: SUMMARYWe have reported a case of E sakazakii primary bacteremia in an elderly patient in whom evaluation failed to reveal a source of infection. This patient had an uneventful recovery after intravenous administration of a third-generation cephalosporin for 7 days followed by 1 week of oral ciprofl

Seizures in patients simultaneously receiving theophylline and imipenem or ciprofloxacin or metronidazole.

Abstract: Five patients had apparently drug-induced seizures while simultaneously receiving theophylline and either imipenem (three patients), ciprofloxacin (one patient), or ciprofloxacin and metronidazole (one patient). Seizures ceased upon reduction in dosage or discontinuation of the suspected offending agents. Imaging studies failed to reveal new structural lesions in the central nervous system in any patient, and only one had a history of neurologic disease. Although the exact mechanism for seizure induction cannot be determined from these cases, potential drug interactions exist, because theophylline, imipenem, and ciprofloxacin are all believed to increase excitation of the central nervous system by inhibition of gamma-aminobutyric acid binding to receptors. In addition, ciprofloxacin decreases the clearance of theophylline from the body, predisposing the patient to elevated theophylline levels. Physicians prescribing theophylline with imipenem, ciprofloxacin, or metronidazole should carefully monitor patients for indications for drug therapy, drug dosage, organ impairment affecting drug metabolism, and signs of toxicity. Seizures may accompany oral theophylline therapy, even at "therapeutic" serum theophylline concentrations.

Poison control centers: can their value be measured?

Abstract: Most regions of the United States are served by poison control centers that provide 24-hour toxicologic guidance resulting in the home management of most poison exposures. It has been suggested that without public access to a poison control hotline the majority of poison-exposed patients wou

Cardiovascular intervention for high-risk families: the Heart Smart Program.

Abstract: :The Heart Smart Family Health Promotion Program is a multidisciplinary, school-based program for cardiovascular risk reduction among high-risk children and their families. As a program that includes young adults at high risk, it is adaptable to a clinical practice. Nineteen fourth and fifth

Rhodococcus equi causing human pulmonary infection: review of 29 cases.

Abstract: :Rhodococcus equi is a gram-positive pleomorphic bacillus that has been identified as a life-threatening pulmonary pathogen in the immunocompromised host. Infection with R equi may go unrecognized by physicians unacquainted with its presentation and unaware of the organism's ability to mimic

Effect of positive end-expiratory pressure on intra-abdominal pressure.

Abstract: Massive elevation of intra-abdominal pressure (IAP) causes renal, cardiovascular, and respiratory dysfunction Positive end-expiratory pressure (PEEP) markedly increases the detrimental effect of IAP on the cardiovascular system The purpose of this study was to determine the effect of PEEP on IAP In 15 patients requiring mechanical ventilation, IAP was measured, after 15-minute equilibration intervals, at PEEP levels of 0, 5, 10, and 15 cm H2O Parametric analysis with multiple paired t tests and nonparametric analysis with Spearman's rho and Kendall's tau tests were used to determine correlation between PEEP and IAP All patients were male The mean age was 39 years (range, 18-77) Ten patients had just had laparotomy No correlation was found between PEEP and IAP We conclude that PEEP of 15 cm H2O or less has no effect on IAP, and we discuss the clinical implications

Invasive aspergillosis in AIDS.

Abstract: Invasive pulmonary aspergillosis was diagnosed in two patients with HIV infection, one with prolonged neutropenia and another receiving corticosteroid therapy. We found 17 additional cases in the literature. A known predisposing risk factor for invasive aspergillosis, eg, neutropenia, corticosteroid use, or intravenous drug abuse, was present in 79% of the cases. That the known immunologic defect of AIDS is not a major host defense against Aspergillus is supported by the empiric observation of the relative rarity of aspergillosis in patients with AIDS. The lung was the most common site of Aspergillus infection (75%), and transbronchial biopsy is diagnostically useful. Central nervous system involvement was seen in 55% and appears to be more frequent in HIV-infected patients than in other immunosuppressed patients with invasive aspergillosis. Prognosis is grim. Despite early institution of amphotericin B therapy in a few cases, the disease was uniformly fatal. Efficacy of therapy with amphotericin B plus rifampin or itraconazole remains to be evaluated. We conclude that aspergillosis is not an AIDS-related opportunistic infection.

Massive bone allografts for traumatic skeletal defects.

Abstract: Large bone allograft transplants have been successfully used to reconstruct skeletal defects created by tumor resections and failed arthroplasties, but little has been reported on their use in traumatic defects. Of approximately 500 allograft procedures done at the Massachusetts General Hospital from 1979 to 1988, 11 were done for restoration of traumatic bone loss. The average age of the patients was 30 (range 11 to 71 years), and the location of the defect was the tibia or femur in 10 of the 11 patients studied. Eight osteoarticular grafts (six hemicondylar and two total condylar) and three intercalary grafts were used for six open and five closed fractures. The time from injury to reconstruction averaged 17 months (3 to 96 months). Primary reconstruction was done in three cases and a salvage procedure in eight. Patients were assessed by the operating surgeon and a physical therapist using an evaluation system that considers function, life-style, and emotional acceptance. According to the system, nine patients had excellent or good results (six hemicondylar grafts, three intercalary grafts), one patient had a fair result (total elbow graft), and one patient had failure of a total condylar graft and subsequently required an amputation. This study suggests that large bone allografts are of value in reconstructing traumatic skeletal defects, especially those involving an articular surface in a young patient.

Hand function in patients with diabetes mellitus.

Abstract: :Using validated clinical tests and standardized controls, we measured hand function in diabetic subjects. Fifteen diabetic patients (median age 48 years), all having used insulin for a minimum of 5 years, were randomly selected from inpatient and outpatient services of an academic medical c

Physicians' psychologic reactions to malpractice litigation.

Abstract: :A questionnaire investigating the psychologic sequelae of malpractice litigation was administered to sued and nonsued physicians through a major malpractice insurer in a rural southern state. Factor analysis showed clusters of symptoms, including psychologic trauma, job strain, shame/doubt,

Postoperative intussusception: increasing frequency or increasing awareness?

Abstract: Postoperative intussusception in children is a rare but well recognized phenomenon. The diagnosis is often delayed due to the protean manifestations of the disorder (ileus, distention, and nausea and vomiting) which, when encountered shortly after an abdominal operation, usually result in a low index of suspicion because they are common after laparotomy. Experience with two cases of postoperative intussusception within 24 hours heightened our index of suspicion. Review of our records indicated we had diagnosed and treated postoperative intussusception in 14 children during the preceding 4 years. Patient ages ranged from 4 months to 12 years (mean 39 months, median 20 months), and symptoms appeared on postoperative days 3 to 36 (mean 10 days, median 6 days). Initial operations included excision of a retroperitoneal or abdominal tumor (five cases), Nissen fundoplication and gastrostomy (three), ileal resection (two), Ladd procedure (one), Duhamel operation (one), and operative reduction of ileocolic intussusception (the two most recent cases). Eleven patients had appendectomy (five by the inversion technique), and three had placement of a transgastric small bowel feeding tube. Nine children had had either barium enema or upper gastrointestinal studies because of the postoperative suspicion of obstruction; one patient had both. Diagnostic studies were not done in four patients. Operative reduction was successful in all but one child, who required bowel resection.

Necrotizing fasciitis and nonsteroidal anti-inflammatory drugs.

Abstract: We have presented a case of fulminant necrotizing fasciitis that occurred after excessive NSAID intake with granulocytopenia. This case parallels those previously reported as outlined in the above discussion. We concur with previous investigators who have concluded that NSAIDs should be used with caution in patients with phlebitis or apparently benign inflammatory cutaneous lesions.

Klebsiella Pneumonia in the Modern Era: Clinicoradiographic Correlations

Abstract: A classic clinical and radiographic picture of Klebsiella pneumonia has emerged in the literature. Patients are typically male, older than 48 years, and have a history of chronic alcoholism. The majority of these pneumonias are community acquired. Bulging interlobar fissures and cavitation are radiographic findings said to be distinctive for Klebsiella pneumonia. We prospectively studied 15 cases of bacteremically proven Klebsiella pneumonia and found clinical and radiographic features strikingly different from those described in the literature. Immunosuppression (from corticosteroids, cytotoxic chemotherapy, neutropenia, hematologic malignancy, and transplantation) now rivals alcoholism as the primary risk factor. Cases tended to be nosocomial rather than community acquired. Neither bulging interlobar fissure nor cavitation was seen in any case. The right upper lobe was involved in 11 of our 15 cases. Pneumonia due to Klebsiella oxytoca was more likely to be isolated from patients with bilateral infiltrates, while Klebsiella pneumoniae was more likely in patients with unilateral infiltrates.

Spectrum of invasive pulmonary aspergillosis in immunocompetent patients with chronic obstructive pulmonary disease.

Abstract: Invasive pulmonary aspergillosis is a well-recognized complication in immunocompromised patients, especially those with neutropenia. We report four cases of invasive pulmonary aspergillosis in patients whose main underlying disease was chronic obstructive pulmonary disease (COPD). Two patients had an acute fatal course, one had chronic necrotizing pulmonary aspergillosis ending in an acute fatal course, and the other had a semiacute disease that responded to amphotericin B. Autopsy on three patients showed invasive pulmonary aspergillosis in both lungs, and tissue invasion was documented by transbronchial biopsy in the patient who survived. Retrospective review of all cultures that grew Aspergillus species from bronchoscopic specimens showed no false-positive results, and this procedure proved to be the most useful maneuver in making the diagnosis. Invasive pulmonary aspergillosis should be in the differential diagnosis in patients with COPD and unexplained pulmonary infiltrates.

Emphysematous pyelitis and emphysematous pyelonephritis characterized by computerized tomography.

Abstract: We report three cases of emphysematous pyelonephritis, all of them associated with perinephric emphysema, and one case of emphysematous pyelitis to demonstrate the value of computerized tomography (CT) in both diagnosis and patient management. The differentiation between air in the collectin

Sick building syndrome.

Abstract: "Sick building syndrome" (SBS) is one of the more colorful terms describing an increasingly common pattern of symptoms found among workers in modern office buildings. Core symptoms include lethargy, mucous membrane irritation, headache, eye irritation, and dry skin. To prompt a diagnosis of SBS, these otherwise common symptoms must be "excessively" reported and primarily "work-related." The World Health Organization now estimates that 30% of new or remodeled office buildings show signs of SBS, and that between 10% and 30% of the occupants of these buildings are affected by SBS. Despite such figures, SBS remains poorly researched and even more poorly understood. The following review provides the clinician an overview of SBS that will allow a more accurate differential diagnosis and will help to prevent the widespread suffering that can accrue when SBS is not quickly recognized.

External fistulas arising from the digestive tract.

Abstract: External abdominal fistulas that arise from the digestive tract are associated with high mortality and prolonged morbidity in terms of infection, malnutrition, and skin excoriation. Such external fistulas most commonly follow anastomotic leak after gastrointestinal surgery. We identified 58 patients seen over a 5-year period at the University of Louisville Hospitals because of external abdominal fistulas that arose from the stomach (8), duodenum (4), small intestine (26), colon (14), biliary tract (9), and pancreas (7). Fifteen patients had multiple fistulas and 32 had high-output fistulas (greater than 200 mL/day). Closure was achieved in 48 patients, and eight of the 10 patients whose fistulas remained open died. Overall mortality was 19%. Principles of management include control of infection, correction of fluid and electrolyte imbalance, nutritional support, proper wound care, and often operative intervention. Multiple staged operations over many months were particularly important in managing complex wounds with large abdominal wall defects and multiple fistulas. Fistula closure is the ultimate goal, and patience is important to achieve it.

Shift work, sleep quality, and worker health: a study of police officers.

Abstract: :The Planning and Analysis Unit of the Lexington Police Department changed from rotating to permanent shift assignments. We report herein the results of patrol officers' responses to the Florida Sleep Questionnaire, the SCL-90 (a symptom checklist), and absentee data. Sleep quality and sleep