Showing papers in "Southern Medical Journal in 1993"

Childhood Sexual Abuse, Depression, and Family Dysfunction in Adult Obese Patients: A Case Control Study

Abstract: One hundred significantly overweight patients sequentially applying to a very low calorie diet (VLCD) program were interviewed to learn how the onset of obesity correlated with other life events. By comparison with a control group of 100 always-slender adults, the obese applicants were found to be different at a highly significant level in the prevalence of childhood sexual abuse, nonsexual childhood abuse, early parental loss, parental alcoholism, chronic depression, and marital family dysfunction in their own adult lives. The obese patients commonly reported using obesity as a sexually protective device; many reported overeating to cope with emotional distress. Inquiry into depression, past sexual abuse, and past or present dysfunctional family life should be added to the current medical evaluation of all obese patients. The resultant findings are likely to be relevant to their treatment, whether for obesity or for other medical conditions.

Mesenteric, Omental, and Retroperitoneal Cysts in Children: A Clinical Study of 22 Cases*

Abstract: Cystic lesions of the mesentery, omentum, and retroperitoneum are rare; from 1956 to 1990, 22 patients had operative treatment for such lesions at our institution. They ranged in age from 1 month to 14 years; 75% were younger than 5 years. All had either an acute abdomen or, more commonly, a silent abdominal mass. In all cases, the histologic diagnosis was lymphangioma. Abdominal ultrasonography was done in all cases after 1977 except for two patients who had an acute abdomen requiring emergency exploration. A cystic abdominal mass was diagnosed in 94% of these cases, but the correct diagnosis of lymphangioma was made prior to surgery in only 24%. Mesenteric cysts are most common in the small bowel mesentery. Omental cysts usually occur singly and are easily resected, but multiple cysts predominate in the mesentery and retroperitoneum. Complete resection was accomplished in 82% of our cases. Two patients required partial bowel resection, and four had partial excision with marsupialization of the cysts. With a mean follow-up of 23 months, we have had three recurrences, but none necessitated reexploration. Extra-abdominal lesions, mainly cutaneous lymphangiomas, developed in two cases. Prognosis is good after surgical excision, but long-term follow-up is advisable because of the possibility of recurrence, even during adulthood.

Anorectal manometry: techniques and clinical applications.

Abstract: Anorectal manometry has gained wide acceptance as a helpful method to objectively assess the apparatus of defecation provided by the anorectal sphincter. The standard manometric evaluation enables measurement of resting and squeeze pressures, as well as of the length of the functional anal canal (high pressure zone [HPZ]). More detailed assessment of radial and longitudinal pressure profiles can also be generated from vector volume and vector symmetry index assessment. Adjuvant techniques using an intrarectal balloon allow assessment of the rectoanal inhibitory reflex (RAIR), rectal sensitivity, capacity, and compliance. Although anorectal manometry can be used as a diagnostic test in diseases such as Hirschsprung's disease, more often it is used to assess common disorders such as chronic idiopathic constipation and fecal incontinence. Anorectal manometry has also been considered as a preoperative evaluation in patients having abdominal and anorectal procedures during which the state of continence can be jeopardized.

Colorectal cancer : metastatic patterns and prognosis

Abstract: From 1979 to 1982, 163 patients with colorectal cancer were found to have distant metastases. Of these, 112 (69%) had metastatic disease at the time of initial diagnosis (synchronous metastases [SM]); in the remaining 51 (31%) metastases developed during the course of the disease (metachronous metastases [MM]). The liver was the most common site of metastasis in both groups (72% and 65%, respectively); with the exception of brain metastasis, liver metastasis had the worst prognosis (median survival time [MST], 9 months). The MST for other sites of metastasis were: lung, 10.5 months; bone, 10 months; multiple sites, 10 months; and brain, 5.5 months. Of the 81 patients with SM in the liver, 38% were treated with single modality therapy and 62% with combined modality therapy. Thirty-three patients had MM in the liver. The median time for development of liver metastases (metastasis-free interval [MFI]) was 17.5 months; only lung metastases developed faster (12 months). MFIs for other sites were 20, 20.5, and 33 months for bone, multiple sites, and brain, respectively.

Carisoprodol (Soma): a new and cautious perspective on an old agent.

Abstract: :Carisoprodol (Soma, others) is a commonly prescribed, noncontrolled, skeletal muscle relaxant whose active metabolite is meprobamate. Patients for whom carisoprodol is prescribed are at risk for meprobamate dependence; several such cases have been reported. Toxicity and withdrawal associate

Abuse of Over-the-Counter Dextromethorphan by Teenagers

Abstract: Dextromethorphan, the d-isomer of the opiate agonist levorphanol, has none of the analgesic or sedative effects associated with the opiates and is approved for over-the-counter use as an antitussive. It is available, in various combinations with other medications, in nonprescription cough suppressant and common cold formulations, and its availability in the United States is not controlled. In this paper we have reported two cases of recreational use of dextromethorphan-containing cough syrup by two unrelated teenage boys. Despite the safety of this medication when used at the recommended dosage, there have been cases of "recreational" use of dextromethorphan as well as death by overdose. Although usually thought to be nonaddictive, dextromethorphan produces a substance dependence syndrome, and physicians should be aware of its abuse potential, particularly by youths.

Surgical treatment of Meckel's diverticulum.

Abstract: Meckel's diverticula are the result of incomplete degeneration of the vitelline duct. It is generally believed that less than 5% of them become symptomatic, the frequency decreasing with age. Meckel's diverticula are most commonly manifested in children by painless lower gastrointestinal bleeding and in adults, as an inflammatory process or obstruction. Definitive diagnosis is usually made at surgery, though the Meckel's scan may suggest a diagnosis preoperatively, especially in the pediatric population. All symptomatic and pathologic Meckel's diverticula should be removed with a segment of ileum. The use of stapling devices, with their ease of use and low complication rate, make it reasonable to remove any Meckel's diverticulum that easily fits in the device. If a diverticulum found incidentally is so broad-based or short that stapling cannot be done without difficulty, it is unlikely to become symptomatic and should be left undisturbed.

Home exposures to chlorine/chloramine gas: review of 216 cases.

Abstract: Chlorine and chloramine gas are frequently produced in the home when cleaning products are mixed These gases are strong irritants with the potential for tissue damage Numerous literature citations report industrial exposures to chlorine/amine gas, but there are few reports regarding home exposures The purpose of this study was to determine symptoms, treatment, and outcome in individuals exposed to these gases in the home All exposures to chlorine/amine gas produced as a result of mixing cleaning products in the home and reported to a Regional Poison Information Center (RPIC) over a 12-month period were reviewed All calls were documented and follow-up was done at appropriate intervals All patients with respiratory embarrassment either at the initial contact or on follow-up were referred to a medical facility Of the 216 patients (ages 12 to 81 years), 200 had resolution of symptoms within 6 hours, whereas only 16 had symptoms for more than 6 hours after exposure; 145 patients were treated at home and 71 received further medical care Ten symptoms were identified, with the majority of patients experiencing more than one Emergency room treatment included oxygen (62 patients), bronchodilators (9 patients), and steroid therapy (3 patients) Of the 70 patients who had chest x-ray films, only one had a positive finding; 41 had arterial blood gas measurements done, and all were within normal limits Only one patient in the study group required admission for continued respiratory distress, but he had a preexisting chronic respiratory problem as well as an upper respiratory tract infection at the time of exposure Although the gas produced by mixing cleaning products in the home can cause severe respiratory irritation, most of the patients exposed to chlorine and chloramine gas can safely be treated at home with comfort measures Appropriate follow-up must be done to determine resolution of symptoms

Multicenter randomized trial of ofloxacin versus cefoxitin and doxycycline in outpatient treatment of pelvic inflammatory disease. Ambulatory PID Research Group.

Abstract: A multicenter randomized comparative trial was done to assess the safety and efficacy of oral ofloxacin (400 mg twice daily for 10 days) versus cefoxitin (2 g intramuscularly) followed by doxycycline (100 mg twice daily orally for 10 days) for the outpatient treatment of uncomplicated pelvic inflammatory disease (PID). Neisseria gonorrhoeae (GC) grew on pretreatment endocervical cultures from 43 of 268 women (16%), and in 30 of 247 women (12%) cultures were positive for Chlamydia trachomatis (Ct). Ninety-five percent (122/128) of the women treated with the ofloxacin regimen and 93% (112/121) of those treated with the cefoxitin/doxycycline regimen had cure or improvement on examination at a minimum of one follow-up visit. All GC species were eradicated by both ofloxacin and cefoxitin. Among women who returned for follow-up, the eradication of C trachomatis was 88% (15/17) for the cefoxitin/doxycycline group and 100% (18/18) for ofloxacin. Side effects were more prevalent in the cefoxitin/doxycycline group (15%) than in the ofloxacin group (7%), nausea/vomiting being the most frequent adverse effect. In this study, it appears that ofloxacin and cefoxitin/doxycycline have similar clinical effectiveness for the outpatient treatment of uncomplicated pelvic inflammatory disease.

Pregnant patients in the intensive care unit : a descriptive analysis

Abstract: :We present a descriptive analysis of experience with pregnant women in the intensive care units at a tertiary hospital. During the period from 1983 through 1990, 38 women were admitted to our intensive care units during their pregnancy or within 2 weeks postpartum. This was a rate of 1 per

Chemotherapy-induced alopecia: new developments.

Abstract: Alopecia (hair loss) is one of the most physically and psychologically distressing side effects of cancer chemotherapeutic drugs. Since its first recognition as a common outcome to most chemotherapeutic agents, only a few trials have been reported, using either a method to temporarily reduce the scalp blood flow (scalp tourniquet or hypothermia) or vitamin E, with undocumented and variable efficacy. The lack of progress in the treatment and prevention of chemotherapy-induced alopecia is in part due to the lack of a reproducible animal model. In the past 2 years, we reported on the following observations: (1) treatment of 8-day-old rats with vidarabine (ara-C), doxorubicin, and cyclophosphamide consistently produced either total body alopecia (ara-C and cyclophosphamide) or alopecia confined to the head and proximal part of the back (doxorubicin); (2) Imuvert, a biologic response modifier derived from the bacterium Serratia marcescens, uniformly produced complete protection against alopecia induced by ara-C and doxorubicin but not that produced by cyclophosphamide; (3) the protective effect of Imuvert against chemotherapy-induced alopecia is mediated by a monocyte-mediated cytokine; and (4) this monocyte-derived cytokine is, possibly, interleukin-1. These observations constitute important progress in the understanding and prevention of chemotherapy-induced alopecia.

Chronic pulmonary aspiration in children.

Abstract: According to established diagnostic and therapeutic guidelines for chronic pulmonary aspiration, clinical suspicion is raised by coughing and choking with feeding, coughing during sleep, recurrent pneumonia, failure to thrive, and radiologic signs of chronic lung injury The upper gastrointestinal series accurately defines anatomy and function, can differentiate between direct and reflux aspiration, and identifies conditions that predispose to aspiration Gastroesophageal scintigraphy lacks anatomic detail but increases observation time, may differentiate between direct and reflux aspiration, and identifies delayed gastric emptying and gastroesophageal reflux The lipid-laden macrophage index improves identification of aspiration, but cannot differentiate between direct and reflux aspiration The esophageal pH probe identifies gastroesophageal reflux Treatment options include medical therapy (thickened feedings, prone positioning, and metoclopramide) and surgical intervention (gastrostomy, fundoplication, and definitive correction of predisposing conditions) Therapy is determined by severity of illness and results of diagnostic evaluation

Advance directives on hospital admission : a survey of patient attitudes

Abstract: A survey of 200 outpatients using an anonymous, self-administered questionnaire revealed that 18% had already completed an advance directive. Only 5% had received information concerning advance directives from their physicians. Eighty-seven percent stated they would not be offended if, on admission to the hospital, they were to be asked whether they had completed a living will. Eighty-eight percent would view such a policy as showing evidence of positive concern by the hospital on their behalf. Only 2% consistently gave a negative response to a proposed policy of hospitals providing information concerning advance directives on admission, and a similar percentage was totally opposed to their use. Of those who had completed an advance directive, 50% had secured the only copy in a safety deposit box. This information, as well as the Patient Self-Determination Act of 1990, which will as of December 1, 1991 require hospitals to provide patients with information about advance directives, creates a new framework for the more efficient use of these important but underused documents.

Pulmonary hypertension and cor pulmonale.

Abstract: This article is directed primarily to primary care physicians. The challenge is to suspect, diagnose, and treat pulmonary arterial hypertension when treatment is most effective and before the effects of cor pulmonale become fully manifested. A good history and physical examination should be followed by electrocardiographic and roentgenographic evaluations. Of additional value are arterial blood gas measurements, two-dimensional echocardiography, first-pass radionuclide angiography, and catheterization of the right ventricle. Chronic obstructive pulmonary disease (COPD) is one of the more common etiologies of pulmonary hypertension and cor pulmonale. COPD is most common in the elderly and cor pulmonale is fairly common among those with COPD; therefore, hypoxic pulmonary hypertension and the resultant cor pulmonale occur mostly in older patients. Because early signs are nonspecific, diagnosis and treatment are often delayed until the pulmonary disorder is severe. Thus it is imperative that the primary care physician be cognizant of this serious problem. Standard treatment of left ventricular failure (ie, "congestive heart failure") could have adverse effects in patients with cor pulmonale.

Disseminated Strongyloides stercoralis infection.

Abstract: A case of disseminated S stercoralis is an immunosuppressed patient manifested with diarrhea, a rash, and progressive respiratory insufficiency. The parasites were eradicated with thiabendazole despite continued steroid therapy, and the patient survived the hospitalization. The characteristics of S stercoralis allow it to be harbored within a host for prolonged periods of time, only to disseminate once cell-mediated immunity is suppressed. A diagnosis of strongyloidiasis should be considered in an immunocompromised patient with a petechial rash. Prompt diagnosis and initiation of thiabendazole therapy provides the greatest opportunity for patient survival. Secondary bacterial infections should be aggressively sought. Mortality from disseminated strongyloidiasis approaches 80%.

Expectations and needs of persons with family members in an intensive care unit as opposed to a general ward.

Abstract: The positive effect of family support on the outcome from serious illness that requires intensive care has been recognized by clinicians for decades We have all seen that family visitation and an intensive care environment more similar to that of a general ward (sunlight, radio, television) can benefit patients with psychosis related to intensive care The severity of illness of the individual patient exerts a powerful stress on the family unit, but it has been difficult to measure this effect We used a 40-question family needs survey with a degree of importance scale to compare the intensive care unit (ICU) with the general ward in terms of impact on the family Five needs were found to discriminate these two environments The family members of patients in an ICU considered it very important (1) for staff to give directions on what to do at the bedside, (2) to receive more support from their own family unit, (3) to have a place to be alone as a family unit in the hospital, (4) to be informed in advance of any transfer plan, and (5) to have flexibility in the time allowed for visitation Family members are willing to accept decreased visitation time if the physicians and nurses can equate this decrease with the complexity of care in the ICU The results of this survey have helped us modify and individualize our approach based on family expectations especially when patients are transferred from the general ward to the ICU or from the ICU to the ward

Amiodarone pulmonary toxicity: a multidisciplinary review of current status.

Abstract: Amiodarone, a benzofuran derivative, has proven useful in the control of serious cardiac arrhythmias. We reviewed the English language medical literature to characterize clinical, radiographic, scintigraphic, pathologic, diagnostic, and prognostic data concerning amiodarone pulmonary toxicity. Our review showed that features consistent with amiodarone pulmonary toxicity include exertional dyspnea, fever, and high sedimentation rates, usually in patients taking larger maintenance doses. Positive findings on gallium scan, foamy alveolar macrophages on lung biopsy or bronchoalveolar lavage, and resolution of abnormal chest roentgenogram upon withdrawal of amiodarone and/or institution of corticosteroid therapy support a diagnosis of amiodarone pulmonary toxicity. Conversely, maintenance doses of 400 mg or less daily, normal lung diffusing capacity and bronchoalveolar lavage or lung biopsy specimens without foamy alveolar macrophages are features that make amiodarone pulmonary toxicity unlikely. Amiodarone pulmonary toxicity should be considered in any patient who has new or clinical worsening of respiratory symptoms and/or abnormalities on chest roentgenogram. Congestive heart failure is often present in these patients and must be excluded before a diagnosis of amiodarone pulmonary toxicity can be considered. Amiodarone pulmonary toxicity also needs to be distinguished from pulmonary infection. Therefore, amiodarone pulmonary toxicity remains a clinical diagnosis relying upon a composite of clinical, radiographic, and histopathologic findings.

Evaluation of flumazenil for reversing the effects of midazolam-induced conscious sedation or general anesthesia.

Abstract: To evaluate the effectiveness of flumazenil in reversing midazolam-induced conscious sedation and general anesthesia, we gave either flumazenil or placebo to 55 patients in a double-blind manner after surgery. Whether surgery was done under conscious sedation (CS group) or general anesthesia (GA group) depended on the procedure. Recovery was assessed by an Observer Assessment of Alertness and Sedation (OAAS) Scale, Finger-Nose (F-N) test, and picture recall and recognition. OAAS and F-N tests were done at baseline, 0 minutes (before the test drug administration), and at 5, 15, 30, 60, 120, and 180 minutes. Picture recall and recognition were tested at 180 minutes and 24 hours, respectively, after test drug administration. Patients who were sedated during surgery (CS group) received a mean of 10.3 +/- 5.3 mg midazolam. The patients receiving general anesthesia (GA group) were given 21.0 +/- 8.2 mg midazolam. In the CS group, improvement in scores on the OAAS scale and F-N test was similar after administration of both flumazenil and placebo. In the GA group, flumazenil produced significantly greater improvement in the OAAS scores at 5 and 15 minutes, and in the F-N test scores at 15 minutes. In both groups, picture recall and recognition improved significantly immediately after flumazenil administration, but this improvement was generally not sustained for pictures shown at later times. These results imply that flumazenil is beneficial for reversing amnesia briefly after midazolam-induced sedation. However, flumazenil hastens recovery only when larger doses of midazolam are used for general anesthesia.

Open trial of fluoxetine therapy for premenstrual syndrome.

Abstract: :To assess the possible efficacy of fluoxetine hydrochloride in severe PMS (premenstrual syndrome, luteal phase dysphoric disorder), an open trial of this medication was undertaken on women with severe PMS. Of 38 patients seeking evaluation of PMS, 35 met the criteria for diagnosis, and 21 h

Overlapping sphincteroplasty for acquired anal incontinence.

Abstract: :Overlapping sphincter repair is the operation of choice for incontinence due to obstetric injuries, trauma, or previous anorectal surgery. We present our experience from 1981 to 1990 using the overlapping sphincter repair for anal incontinence resulting from childbirth in 21 patients (58%),

Multiple cerebral aneurysms in patients with sickle cell disease.

Abstract: Patients with sickle cell disease appear to have a high incidence of cerebral aneurysm. These aneurysms are not associated with the usual risk factors of hypertension, renal disease, or connective tissue disease. We present two recent cases of patients with sickle cell disease and multiple cerebral aneurysms, review the literature on the association between sickle cell disease and cerebral aneurysms, and discuss a mechanism by which sickle cell disease may lead to the formation of cerebral aneurysms.

Nsaid nephrotoxicity revisited : acute renal : failure due to parenteral ketorolac

Abstract: The success of ketorolac as a nonnarcotic analgesic is likely to propagate its widespread use to control moderate to severe postoperative pain. Indeed, of the patients treated with ketorolac and described in the medical literature, nearly 90% had had a major surgical procedure. Since any such procedure may be associated with significant third-spacing of the fluid and result in renal hypoperfusion, care must be taken in administering ketorolac. Close attention to urine output and parameters of renal function must be maintained. Moreover, postoperative ketorolac therapy should be avoided in patients who have conditions that predispose to NSAID nephrotoxicity (as in our Case 1). Likewise, in nonsurgical patients the same degree of caution should be used with ketorolac as with any oral NSAID. Finally, since ketorolac is excreted almost entirely by the kidney, either elderly patients or patients with underlying renal insufficiency must have an adjustment of the dosing interval, or this medication should be avoided in such patients altogether.

Nontuberculous mycobacterial infection of the central nervous system in patients with AIDS.

Abstract: Infections due to nontuberculous mycobacteria (NTM) are especially common in patients with AIDS. Meningitis due to NTM, however, is rare. A search for CSF cultures positive for NTM over the past 11 years at our hospital yielded 16 cases. Of these, 15 were caused by Mycobacterium avium-intracellular (MAI), and one was caused by M fortuitum. All patients with MAI infection had widespread dissemination and at least one risk factor for AIDS. Clinical features included weight loss, altered mentation, and seizures. Analysis of cerebrospinal fluid revealed a mildly elevated leukocyte count with lymphocyte predominance and normal protein and glucose values. All direct smears were negative for acid-fast bacilli. In-hospital mortality was 67%. The patient with infection due to M fortuitum had a preexisting diagnosis of AIDS and had a right upper lobe pneumonia and headaches. Cranial CT showed an enlarged infundibulum of the pituitary gland. Results of CSF analysis were essentially normal, and direct smears were negative. He left the hospital against medical advice. Our study indicates that the finding of MAI in the CSF in patients with AIDS is associated with an in-house mortality of 67% indicating a very poor prognosis.

Superiority of amniotic fluid index over amniotic fluid pocket measurement for predicting bad fetal outcome

Abstract: Semiquantitative amniotic fluid volume (AFV) determination is a component of the fetal biophysical profile (BPP). To assess decreased AVF we did BPPs of 174 fetuses within 1 week of delivery. Two methods were used: measurement of the single largest vertical pocket (oligohydramnios = depth < 1 cm) and the four-quadrant amniotic fluid index (AFI) (oligohydramnios = AFI < or = 5 cm). AFV, as determined by each method, was related to measures of fetal outcome (perinatal mortality, fetal distress, Apgar score, meconium-stained amniotic fluid, and intrauterine growth retardation [IUGR]). The AFI was more sensitive in predicting mortality (87.5%) and the following measures of perinatal morbidity: low 5-minute Apgar score (88.8%), fetal distress during labor (86.6%), meconium-stained amniotic fluid (63.6%), and the presence of IUGR (79.4%). The sensitivity of amniotic fluid pocket measurement of < 1 cm was 75%, 72.2%, 66.6%, 47.7%, and 55.8%, respectively, for the same measures. Using the AFI instead of a single pocket measurement in BPP assessment increased the sensitivity and positive predictive value of the BPP from 64.7% to 76.4% and from 45.8% to 68.4%, respectively. Our data suggest that qualitative AFV measurement using the AFI is superior to that of the single largest pocket in multiple component fetal biophysical testing.

Use of tympanic thermometers to screen for fever in patients in a pediatric emergency department

Abstract: :The use of tympanic thermometers has markedly increased over the past few years. While some authors have shown high correlation between rectal and tympanic readings, others have found low correlation. After noticing a failure of the tympanic thermometer to detect fever in obviously febrile

Eustachian tube dysfunction and its sequelae in patients with cleft palate.

Abstract: The incidence of middle ear disorders in patients with cleft palate deformities was determined in a retrospective review of 110 children with palate or palate and lip involvement. Ages ranged from 2 months to 18 years and included patients with associated abnormalities such as Pierre Robin syndrome and Treacher Collins syndrome. Clinical manifestations of eustachian tube dysfunction were found in 79% in the form of effusions, retraction pockets, adhesions, and ossicular erosion. Only two patients had confirmed cholesteatoma formation. Despite the low incidence of acquired cholesteatoma in these patients, the frequent occurrence of other disorders that affect hearing warrants early and aggressive otologic management to prevent long-term sequelae.

Ribavirin and intravenous immune globulin therapy for measles pneumonia in HIV infection.

Abstract: We have described a patient, immunocompromised from an infection with the human immunodeficiency virus, who had rapidly progressive measles complicated by measles pneumonia and respiratory failure. Rapid improvement in the patient's condition followed therapy with inhaled ribavirin and intravenous immune globulin. Patients who have measles pneumonia associated with respiratory failure may benefit from combination therapy with ribavirin and IV immune globulin.

Systemic lidocaine therapy for poststroke pain.

Abstract: Poststroke pain syndrome is commonly regarded as an intractable disease. We describe four patients who responded to an intravenous lidocaine infusion for relief of central pain after a stroke. The infusion was administered over a 48-hour period after an initial bolus of 50 to 100 mg intravenously over 40 to 120 seconds. Pain intensity and pain relief were measured by visual analog and numeric scales. All patients reported some relief within the first 12 hours of infusion. All patients were subsequently given a trial of mexiletine, an oral congener of lidocaine. Two have continued taking the drug and report excellent relief at 12 months' follow-up; the other two had side effects that precluded further use of the drug. We conclude that lidocaine can reduce poststroke pain, and we propose a treatment algorithm based on our experience with 40 additional patients treated for other neuropathic pain states.

Necrotizing infections of the perineum.

Abstract: During a 6-year period, 10 patients were treated for severe necrotizing infections of the perineum (Fournier's gangrene) at the Edward Hines Veterans Administration Hospital (Hines, Ill). All were male, and their average age was 60 years. When known, duration of symptoms was 2 to 5 days. Prodromal signs such as edema, erythema, and pain frequently developed into rapidly spreading, full-thickness cutaneous gangrene in less than 24 hours. All patients had significant concomitant disease; 60% were diabetic. All patients had expedient and aggressive initial debridement, usually within 24 hours of presentation to the surgical service. Each patient had a "second-look" debridement within 1 or 2 days. Debridement was done an average of 2.6 times per patient. The cause of the infection was noted in seven patients--five with perirectal abscess and two with urethral trauma. Suprapubic catheters were placed in both patients with urethral trauma. Diverting colostomy was done on two patients who had perirectal abscess as a nidus; eight patients were treated without colostomy. Polymicrobial bacteriologic flora were found in all patients, with a predominance of Escherichia coli, Bacteroides sp, and staphylococci. Broad spectrum antibiotics and early nutritional supplementation were given. Hospital stay averaged 4 weeks (range, 3 to 12 weeks). One patient died (mortality of 10%). Successful management of these patients requires expedient diagnosis, aggressive nutritional supplementation, and early and repeated debridement as clinically indicated. We have not found diverting colostomy to be a necessary part of the management of these patients even when the nidus is perirectal.