Showing papers in "Southern Medical Journal in 1992"
178 citations
TL;DR: For those individuals who feel powerless or helpless, suicide may be a means of taking control over their helplessness and whether the individual will adapt or become maladaptive.
Abstract: All occupations are associated with stress, but certain occupations are significantly more stressful than others. Stress is not always harmful. It is the individual's reaction to stress that determines the outcome, ie, whether the individual will adapt or become maladaptive. Individuals who feel they can control events or are in control of their lives are better able to handle stress than individuals who believe they are the victims of fate or chance and who feel powerless and helpless. For those individuals who feel powerless or helpless, suicide may be a means of taking control over their helplessness. Police officers, who are subject to extraordinary stress, present a paradigm for the study and treatment of stress in other occupations.
76 citations
TL;DR: The difficult assessment of risk and the long latency period for development of disease demand evaluation and regular surveillance of asbestos-exposed workers are discussed.
Abstract: Asbestos is a versatile fibrous mineral that can cause lung disease and death. Asbestosis, benign pleural disease, lung cancer, and mesothelioma can all result from inhaling asbestos. The history of disease and exposure risks are discussed. The difficult assessment of risk and the long latency period for development of disease demand evaluation and regular surveillance of asbestos-exposed workers.
75 citations
TL;DR: A 43-year-old man with dysphagia and a tendency to aspirate was found to have squamous cell carcinoma of the esophagus and went into cardiorespiratory arrest caused by pulmonary edema, and died.
Abstract: A 43-year-old man with dysphagia and a tendency to aspirate was found to have squamous cell carcinoma of the esophagus. Curative surgery was planned and preoperative computed tomography of the chest and abdomen was ordered. A ward nurse administered Gastrografin according to a "standing" order, 4 hours before the CT was to be done. The patient aspirated about 50 mL of Gastrografin, and went into cardiorespiratory arrest caused by pulmonary edema. He sustained severe brain damage and died. This is a first report of lethal aspiration of Gastrografin, given in preparation for CT. We advise alerting nurses who administer Gastrografin, especially to patients with dysphagia or impaired consciousness about the grave consequences that can result if the contrast agent is aspirated by the patient. We further advise that responsibility for using contrast agents in radiologic procedures be assumed by the radiologist and not by medical house staff.
69 citations
TL;DR: This work presents two cases of wandering spleen manifested as a lower abdominal mass, and discusses the surgical anatomy of the spleen and splenic ligaments and the hypothetical responsibility of these ligaments for the genesis of this clinical entity.
Abstract: Wandering spleen is a rare clinical entity and remains an elusive clinical diagnosis, particularly in the pediatric patient. Among the imaging modalities (computerized tomography, magnetic resonance imaging, nuclear medicine, ultrasonography, plain films) used in the diagnosis of wandering spleen, ultrasonography is the least invasive and most effective. Elective splenopexy remains the treatment of choice when the diagnosis is made before splenic infarction. We present two cases of wandering spleen manifested as a lower abdominal mass, and we discuss the surgical anatomy of the spleen and splenic ligaments and the hypothetical responsibility of these ligaments for the genesis of this clinical entity.
64 citations
TL;DR: In this series, nine pregnant patients had appendectomy; pyuria and symptoms suggesting urinary tract infection delayed diagnosis in one whose appendix perforated, and there were five maternal deaths, all in the group of patients with perforation.
Abstract: In this series, nine pregnant patients had appendectomy. Seven patients had acute appendicitis; pyuria and symptoms suggesting urinary tract infection delayed diagnosis in one whose appendix perforated. Abdominal pain and nausea with or without vomiting were presenting symptoms in all of the patients. Tenderness in the right lower quadrant was present in six. Eight patients, including two with a normal appendix, had leukocytosis with a left shift. There was no fetal or maternal loss. In addition, I reviewed more than 900 other cases of appendectomy during pregnancy, as reported in the literature since 1960. Among 713 previously reported cases of confirmed appendicitis, rupture had occurred in 25%. There were five maternal deaths, all in the group of patients with perforation. Perinatal mortality was 4.8% among patients with acute inflammation only and 19.4% in those with perforative appendicitis. The diagnosis rests on clinical acumen, and prompt surgical intervention is the key to good outcome.
61 citations
TL;DR: In patients at risk for ill effects from the tachycardia and hypertension that may accompany sympathetic nervous system response to ECT, nitroglycerin, propranolol, hydralazine, or other sympatholytic agents should be used to attenuate the potentially harmful sequelae of ECT.
Abstract: Electrically induced seizures have been used widely to treat psychiatric disease since their introduction in 1938. Seizure activity is the therapeutic aspect of this form of treatment, but it is accompanied by untoward physiologic consequences. Cardiovascular responses consist of generalized autonomic nervous system stimulation with initial parasympathetic outflow, followed immediately by a sympathetic response. In certain patients the sequence described may result in an initial bradycardia or even asystole, followed by tachycardia, dysrhythmia, and hypertension. The cerebrovascular system responds with a marked increase in cerebral blood flow in response to increased cerebral oxygen consumption, and dramatic elevation of intracranial pressure. General anesthesia for electroconvulsive therapy (ECT) must be administered only in locations equipped for support of the unconscious patient and treatment of complications. Intravenous access is mandatory in all patients, as is monitoring of blood pressure, and ECG, as well as pulse oximetry. Appropriate oxygen supplementation and ventilatory support are essential as they are during any procedure necessitating general anesthesia. Methohexital, 0.75 to 1.0 mg/kg intravenously, is the most frequently used agent for induction of anesthesia for ECT; muscle relaxation usually is accomplished with succinylcholine, 0.5 to 1.0 mg/kg. In patients at risk for ill effects from the tachycardia and hypertension that may accompany sympathetic nervous system response to ECT, nitroglycerin, propranolol, hydralazine, or other sympatholytic agents should be used to attenuate the potentially harmful sequelae of ECT. The efficacy of ECT requires a knowledge of anesthetic precepts, an understanding of the interaction between anesthetic drugs and seizure activity, and an awareness of the physiologic effects of ECT as well as the treatment of those effects.
55 citations
TL;DR: Results indicate that the drug problem on the authors' highways may be greater than previously recognized and more than half of the drivers using alcohol also had drugs detected on the screening examination.
Abstract: During a recent 5-month period, 201 injured drivers were admitted to a level 1 trauma center. Blood alcohol concentrations (BACs) and drug screens were obtained in 187 and 164 subjects, respectively. BACs were positive in 37% and other drugs were confirmed in 40%, suggesting that alcohol and drug use among injured drivers is comparable. More than half of the drivers using alcohol also had drugs detected on the screening examination. Other investigators have previously established driving impairments associated with some of these drugs. These results indicate that the drug problem on our highways may be greater than previously recognized.
51 citations
TL;DR: In these women of low socioeconomic status, approximately one third of those referred for treatment of dysplasia were noncompliant with referral.
Abstract: This paper reports results of a project designed to examine factors related to compliance with referral for follow-up and treatment of cervical dysplasia. Women studied had cervical dysplasia diagnosed by Pap smear between May 1989 and April 1990. These women had regular follow-up at the gynecology clinic of the Reynolds Health Center in Winston-Salem or at one of 14 county health departments in northwestern North Carolina. Data were collected by chart review, and included age, race, place of residence, marital status, parity/gravidity, education, previous papillomavirus infections, method of payment, and previous Pap smear results. Patients were traced through the treatment protocol, and compliance was assessed at each appointment. In these women of low socioeconomic status, approximately one third of those referred for treatment of dysplasia were noncompliant with referral.
50 citations
TL;DR: It is concluded that 2% clindamycin vaginal cream offers similar efficacy and safety to standard oral metronidazole therapy for bacterial vaginosis.
Abstract: Bacterial vaginosis is common among patients seen by gynecologists. Several types of therapy have been proposed. The purpose of this prospective, randomized, double-blind clinical trial was to examine the efficacy of clindamycin vaginal cream for the treatment of bacterial vaginosis. Sixty patients with symptoms of bacterial vaginosis were randomized into the study, and 46 completed the protocol. Twenty-three patients received 2% clindamycin vaginal cream (5 g applied intravaginally at bedtime for 7 days), with placebo oral tablets twice daily for 7 days. The other 23 patients received oral metronidazole tablets (500 mg twice a day for 7 days) and placebo vaginal cream (5 g intravaginally for 7 days). The cure rates for the two regimens were comparable. Twenty-two (97%) of the patients treated with clindamycin vaginal cream had improvement or cure at the first follow-up visit versus 19 (83%) of those taking metronidazole. There was no statistically significant difference between the two results. Side effects for both regimens were comparable. We conclude that 2% clindamycin vaginal cream offers similar efficacy and safety to standard oral metronidazole therapy for bacterial vaginosis.
46 citations
TL;DR: It is suggested that respite care for demented persons living at home significantly reduces the stress among caregivers, and no difference occurred in rates of institutionalization between those receiving and not receiving day care.
Abstract: The purpose of this study was to determine whether providing respite care to persons with Alzheimer's disease and other dementias decreased stress and mood disturbances in caregivers. Caregivers of persons receiving respite care (n = 7), and not receiving respite care (n = 8) were tested at entry into the study and at 5 weeks and 10 weeks, using the Profile of Mood States and the Relative's Stress Scale. Using repeated measures analysis of variance, a downward trend for study subjects and an upward trend for controls was found for Relative's Stress Scores. Similar trends were found on the Personal Distress Subscale of the Relative's Stress Scale. No difference occurred in rates of institutionalization between those receiving and not receiving day care. Our study suggests that respite care for demented persons living at home significantly reduces the stress among caregivers.
TL;DR: The patient's trichotillomania (hair pulling) was treated with psychotherapy, behavior modification, and various medications, without success, and the tricyclic antidepressant clomipramine (Anafranil) may be of benefit in such cases.
Abstract: We have reported the case of a mildly retarded woman in whom an obsessive-compulsive disorder of hair eating (trichophagia) had begun between 2 and 3 years of age. Over the next 30 years, multiple complications of trichophagia included trichobezoars, malnutrition, intestinal obstruction, and ulceration with bleeding. One of the bouts of intestinal obstruction was associated with the superior mesenteric artery blocking the duodenum. This complication has not been reported previously in this disorder. The patient's trichotillomania (hair pulling) was treated with psychotherapy, behavior modification, and various medications, without success. The tricyclic antidepressant clomipramine (Anafranil) may be of benefit in such cases.
TL;DR: By increasing knowledge of the action and effects of drugs in the elderly, and by enhancing communication and understanding between physician and patient, the authors can significantly improve the overall quality of care for the elderly patient.
Abstract: The segment of the population older than 65 accounts for about 25% of the total drug expenditures in developed countries. This figure is predicted to reach 40% by the year 2030. Drug therapy in the elderly can be complicated by many factors. The pharmacokinetic processes of absorption, distribution, metabolism, and elimination are altered by the physiologic changes of aging involving body composition and organ function. While the extent of drug absorption is not affected by age, few drugs have delayed rates of absorption after oral administration. Changes in body composition, protein binding, and blood flow do affect the concentrations of free unbound drug, the volume of distribution, and elimination half-life of a number of drugs. The primary goal of drug therapy in the elderly is to improve the quality of life. When medical therapy is required, the physician must be aware of the potential effect of age and disease on pharmacokinetics and pharmacodynamics and of the possible ramifications for adverse drug reactions or interactions. By increasing our knowledge of the action and effects of drugs in the elderly, and by enhancing communication and understanding between physician and patient, we can significantly improve the overall quality of care for the elderly patient.
Journal Article•
TL;DR: It is found that swab specimens reflected surface colonization and that needle aspiration seemed to underestimate bacterial isolates as compared with deep tissue biopsy specimens, recommending that antibiotics not be routinely used for treatment of colonization in pressure sores.
Abstract: Diagnosis of the bacterial component of pressure sores is notoriously difficult. We comparatively studied three methods of specimen collection from 72 pressure sores. Specimens taken by swab or by needle aspiration were compared with deep biopsy specimens as to diagnostic reliability. We found that swab specimens reflected surface colonization and that needle aspiration seemed to underestimate bacterial isolates as compared with deep tissue biopsy specimens. We recommend that antibiotics not be routinely used for treatment of colonization in pressure sores; in patients with sepsis, deep biopsy specimens can accurately diagnose infection.
TL;DR: Analysis of all published cases and Food and Drug Administration reports of retinopathy attributed to hydroxychloroquine sulfate (Plaquenil) does not reveal any evidence of permanent visual field scotoma occurring, and a modified Amsler grid screening test for the central 10$$ of visual field is described.
Abstract: Analysis of all published cases and Food and Drug Administration (FDA) reports of retinopathy attributed to hydroxychloroquine sulfate (Plaquenil) does not reveal any evidence of permanent visual field scotoma occurring when the daily dose is related to body weight and does not exceed 6.5 mg/kg for maintenance therapy. Risk factors of unknown degree may appear at this dosage level only when the duration of treatment exceeds 10 years or when chronic renal insufficiency is present. In the absence of risk factors, annual ophthalmologic examinations and central field testing are recommended because non-drug-related macular diseases commonly occur in the older age group. When risk factors are present, more frequent examinations are indicated. A modified Amsler grid screening test for the central 10 degrees of visual field is described and the participation of the treating physician in the testing program is encouraged to provide maximal medicolegal protection.
TL;DR: The prevalence of left ventricular endocarditis in the population is higher than expected and it is imperative that careful consideration be given this entity often encountered in IV drug abusers.
Abstract: Endocarditis in IV drug abusers involves the right side of the heart with much higher incidence than in the general population, being limited to the left in 30% to 40% of cases. The infecting organism is Staphylococcus aureus approximately 50% of the time, followed by Streptococcus (all groups), which accounts for 15% of all cases. In a retrospective study of infective endocarditis in IV drug abusers treated at Charity Hospital over a 5-year period, 67 patients had vegetations documented by two-dimensional echocardiogram. Left-sided involvement was present in 38 (57%) of these patients, a higher prevalence than reported in the literature in such populations. Right-sided involvement was limited to only 27 (40%). A total of 55 patients had positive blood cultures, most of which yielded Staphylococcus aureus (32 [58%]), with the next largest group being Streptococcus species (14 [25%]). This distribution of isolates was consistent with that found in the literature. From these data we conclude that the prevalence of left ventricular endocarditis in our population is higher than expected. With the known increase in morbidity and mortality of left-sided endocarditis as compared to right, it is imperative that careful consideration be given this entity often encountered in IV drug abusers.
TL;DR: This work has reported an additional case of isolated solitary splenic metastasis from primary adenocarcinoma of the rectum.
Abstract: Splenic metastasis is a late manifestation of disseminated disease. Focal metastatic splenic involvement, however, without evidence of additional systemic disease, is unique. Review of the literature yielded only one case of isolated splenic metastasis incidental to rectal carcinoma. We have reported an additional case of isolated solitary splenic metastasis from primary adenocarcinoma of the rectum. Theoretically, certain anatomic, histologic, and functional splenic attributes may limit splenic involvement from metastatic disease.
TL;DR: It is concluded that bulbar dysfunction is not the reason for weight loss in PD, and patients with PSP had significantly worse dysphagia and dysarthria than the patients with PD.
Abstract: Low body weight is a characteristic symptom of Parkinson's disease (PD), but the mechanism is unknown. To determine whether bulbar involvement is responsible for the weight loss, we compared the mean body weight (MBW), height, and body mass index (BMI) of 281 patients with PD and 86 patients with progressive supranuclear palsy (PSP). Although the patients with PSP had significantly worse dysphagia and dysarthria than the patients with PD, their MBW and BMI were not appreciably different. We conclude that bulbar dysfunction is not the reason for weight loss in PD.
TL;DR: The patient was initially thought to have lymphoma, but at operation she was found to have sarcoidosis with splenic involvement, and it is concluded that sarcoids must be considered in the differential diagnosis of splenomegaly.
Abstract: We have presented a case of massive splenomegaly. Our patient was initially thought to have lymphoma, but at operation she was found to have sarcoidosis with splenic involvement. At 2250 g, the spleen was one of the largest recorded in the literature on sarcoidosis. Although the spleen is frequently involved in sarcoidosis, a review of 6074 cases showed that the incidence of actual splenomegaly is only 10%. In 628 of these cases the authors described various degrees of splenomegaly, but the incidence of massive splenomegaly was only 3%. We conclude that sarcoidosis must be considered in the differential diagnosis of splenomegaly.
TL;DR: Residents who had breast-fed, those with spouses who had Breastfeeding, and those with children of their own had the greatest knowledge and confidence base in several areas, such as their ability to teach breast-feeding techniques and to treat cracked nipples.
Abstract: :Pediatricians are expected to offer information and advice on breast-feeding to expectant and lactating mothers, but the educational experience for pediatric residents may not adequately prepare them for this responsibility. To examine knowledge and confidence regarding breast-feeding gaine
TL;DR: It is concluded that race and sex differences do affect the metabolic control of patients with diabetes mellitus.
Abstract: The effect of race on differences in metabolic control was examined in patients with non-insulin-dependent (NIDDM) and insulin-dependent (IDDM) diabetes mellitus. Data were collected on HbA1c, age, duration of diabetes, age at onset, family function, stress, body mass index, waist/hip ratio, total cholesterol, insulin dose, diet, and physical activity. Among those with NIDDM, black patients had significantly higher HbA1c levels than their white counterparts. This difference persisted after adjustment for covariates. Among patients with IDDM, black subjects were found to have higher HbA1c levels, body mass index, and total cholesterol levels than their white counterparts. After correction for diabetes duration, relative insulin dose, physical activity, body mass index, and cholesterol, black women had significantly higher HbA1c levels than black men, white men, or white women. We conclude that race and sex differences do affect the metabolic control of patients with diabetes mellitus.
TL;DR: By being aware and using a simple questionnaire, the clinician may readily identify overlooked factors, such as sleep disorders and depression, when assessing cases of chronic pelvic pain.
Abstract: Assessment of cases of chronic pelvic pain presents a challenging problem, and many physicians overlook the association of sleep disorders and depression with such pain We examined these linkages in our chronic pelvic pain clinic, using a questionnaire that assists in diagnosis and management of these cases To date, the cases of 72 patients (both physician- and self-referred) with pelvic pain have been evaluated Of these patients, 51 of 71 (72%) reported sleep disorders, and 37 of 72 (51%) had clinical depression, as determined by the Beck Depression Inventory After adjustment for a sleep-related item on the Beck scale, these two measures showed a positive correlation of 355 (P < 01) The scores of pain patients differed significantly from those of a control group of asymptomatic patients on the depression and sleep disorder measures By being aware and using a simple questionnaire, the clinician may readily identify overlooked factors, such as sleep disorders and depression, when assessing cases of chronic pelvic pain
TL;DR: In October 1988, five of seven members of a Florida family were poisoned withThallium, constituting the largest outbreak of acute thallium poisoning in the United States since thallum was banned as a rodenticide in 1972.
Abstract: In October 1988, five of seven members of a Florida family were poisoned with thallium, constituting the largest outbreak of acute thallium poisoning in the United States since thallium was banned as a rodenticide in 1972. Three patients had an acute severe neuropathy with respiratory depression; one died. The other two had no symptoms. No cases were identified among nonhousehold relatives or friends, or in the community. Of the more than 100 environmental specimens collected at the family household and tested by atomic spectroscopy, three empty and four unopened glass soft drink bottles of the same lot number yielded thallium in a concentration fatal to humans. All family members who consumed the soft drink were poisoned (5/5) as compared with none of those who did not (0/2). Because poisoning was clustered to the family and police investigators provided evidence that the poisoning was deliberately targeted to the family, it was assumed that no other soft drink bottles contained thallium, and it was decided not to recall all soft drink bottles with the same lot number. A year later a neighbor of the family was arrested and convicted of the murder.
TL;DR: If evidence of pancreatic involvement occurs during sulfonamide therapy, the medication should be discontinued immediately and, if necessary, be replaced by an alternative.
Abstract: We have reported a case of sulfonamide-induced acute pancreatitis. A review of the literature showed only eight previously reported cases. Adverse reactions to sulfonamides are well known, but acute pancreatitis is a very serious complication. If evidence of pancreatic involvement occurs during sulfonamide therapy, the medication should be discontinued immediately and, if necessary, be replaced by an alternative. Other causes of pancreatitis must be excluded.
TL;DR: Induction and maintenance amphotericin B therapy was given to all but 2 patients, and currently 8 of the 23 are alive, and the combination of these four tests revealed the diagnosis of DH in 23 of 23 patients.
Abstract: Disseminated histoplasmosis (DH) is recognized as an opportunistic infection in patients with the human immunodeficiency virus (HIV), especially in regions where histoplasmosis is endemic. At the Kansas University Medical Center 148 patients were hospitalized with the diagnosis of AIDS from December 1983 to March 1991; 23 of these patients (16%) had disseminated histoplasmosis. The charts of these 23 patients were reviewed. Clinical signs and symptoms included fever (91%), cough (65%), and weight loss (48%). Splenomegaly, hepatomegaly, or lymphadenopathy was present in 52% of all patients. Anemia (39%), leukopenia (65%), and thrombocytopenia (52%) were common, and 22% had pancytopenia. Diagnosis was made by peripheral smear examinations (organisms visualized on 7 of 22 smears [32%]), blood cultures (positive for H capsulatum in 16 of 20 patients, [80%]), bone marrow cultures (positive in 14 of 15 patients, [93%]), and bone marrow aspirate and biopsy examinations (organisms seen on 18 of 21 stains, [86%]). The combination of these four tests revealed the diagnosis of DH in 23 of 23 patients (100%). Induction and maintenance amphotericin B therapy was given to all but 2 patients, and currently 8 of the 23 are alive. DH is a common opportunistic infection in AIDS patients from regions endemic for histoplasmosis. When DH is suspected, a peripheral smear examination, blood cultures, bone marrow cultures and bone marrow aspirate and biopsy should be done to make the diagnosis, since suppression of the disease is possible with appropriate therapy.
TL;DR: Differences across medical specialty and respondents' interest in various medical education topics to remedy knowledge deficits are discussed.
Abstract: We conducted a statewide survey to identify physicians' experiences, attitudes, and practices related to HIV-infected patients. A random sample, stratified by medical specialty (primary care, surgery, emergency medicine), was drawn. Physicians were concerned about contagion and inadequate kn
TL;DR: The five patients reported herein, had various archery-related injuries of the upper extremities, which included arrow laceration of a digital nerve and artery, contusion of forearm skin and subcutaneous tissue, and compression neuropathy of digital nerves from the bowstring.
Abstract: The five patients reported herein had various archery-related injuries of the upper extremities. Acute injuries included arrow laceration of a digital nerve and artery, contusion of forearm skin and subcutaneous tissue, and compression neuropathy of digital nerves from the bowstring. Chronic injuries included bilateral medial epicondylitis and median nerve compression at the wrist, de Quervain's tenosynovitis, and median nerve compression at the elbow. Essential measures for archery safety include use of archery protective gear, use of a light-weight bow, conditioning of the forearm flexor muscles, and modifications in drawing the bowstring.
TL;DR: The two infants were delivered during a 2 1/2-year interval in a newborn population in which prenatal cocaine exposure rose to an estimated 25%.
Abstract: We have reported two cases of sirenomelia sequence associated with a history of cocaine exposure during a major part or the entire extent of the first trimester of pregnancy. The two infants were delivered during a 2 1/2-year interval in a newborn population in which prenatal cocaine exposure rose to an estimated 25%. The incidence of sirenomelia in this population was 18-fold higher than previously reported. The potential relationship between sirenomelia and cocaine exposure during the first month of pregnancy warrants further investigation.
TL;DR: A critical review of controlled and uncontrolled studies examining the use of methylphenidate hydrochloride as an antidepressant and practical guidelines for identifying patients who are potential candidates for treatment with MPH are provided.
Abstract: :The use of psychostimulants as antidepressants remains controversial in the field of psychiatry. While methylphenidate hydrochloride (MPH) and dextroamphetamine (DA) are often considered to be equivalent drugs, differences in their neurobiologic mechanism of action may account for different
TL;DR: In those hands that regained at least 100% of their preoperative grip strength at 3 or more months, there was an average increase in maximal grip of 56%, as compared with an average decrease of 20% in the remaining hands.
Abstract: We prospectively studied preoperative and postoperative grip and pinch strength in 21 patients having 30 consecutive median nerve decompressions for carpal tunnel syndrome. All procedures were done by one surgeon. Each hand operated on served as its own control and was studied by the same therapist preoperatively and at monthly intervals for 6 months after the procedure. An initial decline in both grip and pinch strength was noted in most hands during the first postoperative month. Eighty percent or more grip strength was regained in 65% of the hands at 2 months and in 81% at 3 or more months. In those hands (65%) that regained at least 100% of their preoperative grip strength at 3 or more months, there was an average increase in maximal grip of 56%, as compared with an average decrease of 20% in the remaining hands (35%).