Showing papers in "Southern Medical Journal in 1996"

Laparoscopic versus open appendectomy.

Abstract: This prospective clinical study was done because our initial retrospective review suggested that laparoscopic appendectomy (LA) offers no significant advantages over open appendectomy (OA) yet is significantly more expensive. From July 1992 to August 1993, 57 patients were approached preoperatively for randomization to either LA (n = 19) or OA (n = 18). There were no statistically significant differences between the LA and OA groups in operative risk: mean age, 28 +/- 2 vs 26 +/- 2 years; percent female, 26% vs 22%; body mass index, 24 +/- 0.8 vs 26 +/- 1.2 kg/m2. All patients were either ASA class I or class II, 78% in each group being class II. The differences between the LA and OA groups in mean operating time required (93 +/- 12 vs 87 +/- 8 minutes), postoperative intramuscular narcotic analgesic usage (24 +/- 6 vs 26 +/- 6 hours), postoperative hospital stay (57 +/- 12 vs 66 +/- 10 hours), and return to normal activity (20 +/- 6 vs 14 +/- 3 days) were also not significant. However, LA was much more expensive because of higher operating room charges. The mean total hospital bill was $4,600 +/- $160 for the LA group and $1,700 +/- $70 for the OA group. This prospective study corroborated our previous analysis. Laparoscopic appendectomy is safe, effective, and expensive and overall has no greatly significant advantages over open appendectomy.

Tracheobronchial foreign body aspiration in children.

Abstract: In this retrospective study, we reviewed the demographic and radiographic findings of 155 children with bronchoscopy-proven tracheobronchial foreign body aspiration (FBA). Two thirds of the patients were male, and most were children between 1 and 2 years of age. An aspirated peanut accounted for one third of all cases. Foreign body location was distributed nearly evenly to the right and left primary bronchi; tracheal foreign body was noted in 16 patients. The most frequent symptoms of FBA were cough (85 patients) and wheezing (60 patients). Although most patients were seen within 1 day of aspiration, 30 patients had symptoms that lasted at least 1 week before diagnosis. The most common radiographic findings were unilateral or segmental hyperlucency (59) or atelectasis (38). The trachea was the site of the foreign body in one half of children with a normal chest radiograph and FBA.

Medical complications of glue sniffing.

Abstract: Glue sniffing refers to the deliberate inhalation of volatile solvents, commonly found in adhesives, for the purpose of intoxication. The increasing prevalence of inhalant use suggests that many physicians will encounter a glue-sniffing patient at some time during their practice. Knowledge of the epidemiology, toxicology, and medical complications associated with glue sniffing is essential in obtaining an accurate history of substance abuse and in clinically managing these patients. This review of sources is intended to aid clinicians in the recognition of glue-sniffing patients and in the diagnosis of acute and chronic medical complications associated with the abuse of glues, solvents, and related substances. Glue sniffing has been linked to sudden death and chronic damage to the heart, lungs, kidneys, liver, peripheral nerves, and brain. Inhalant abuse in general is associated with mortality and morbidity, including social, educational, and economic deprivation in adolescents and young adults.

Intrathecal Infusion Systems for Treatment of Chronic Low Back and Leg Pain of Noncancer Origin

Abstract: :In this study, 26 patients (average age, 44.3 years) with chronic noncancer pain averaging 115 months' duration had implantation of an infusion pump with intrathecal catheter placement. In general, preservative-free morphine sulfate was used. Average follow-up was 23 months. Measurements of

Dysphonia in the elderly: diagnosis and management of age-related voice changes.

Abstract: In our laryngology practice, we have noted an increasing number of elderly patients referred to us for problematic dysphonia. We present our findings of the most common disorder affecting this age group. A sample of 47 consecutive patients over age 60 with dysphonia revealed presbylaryngis, ie, age-related anatomic and physiologic changes, as the most common etiology found in this tertiary referral practice, accounting for 30% (14 patients) of new diagnoses. None of the patients with presbylaryngis received this diagnosis from the referral source. Understanding the anatomic and physiologic changes of the aging vocal tract, along with the clinical correlation of each change, is crucial in evaluating this group of patients. Managing this disorder includes specific goal-oriented speech therapy, with surgery as an adjunct should conservative therapy prove unsuccessful. Earlier recognition of this disorder and prompt intervention are key factors in reversing vocal decompensation, with a primary effect of improving the quality of life for the patient with age-related dysphonia.

Patient understanding of emergency department discharge instructions

Abstract: Patients were interviewed immediately after discharge outside the emergency department to determine whether they could read their discharge instructions and recall their diagnosis and treatment plan. The association between frequency of correct responses and various characteristics of the patients was assessed. Of the patients completing the interview, 72% could read the discharge instructions. The illiteracy rate was higher for patients with less than 9 years of education and for patients aged 50 to 59 years. There was no association between patient race, sex, or literacy. The correct diagnosis was given by 79% of patients, correct treatment information by 49%, and correct follow-up information by 82%. Overall, 37% of patients answered all questions correctly and 8% answered all questions incorrectly. No association was found between frequency of correct responses and variables examined. Miscommunication of discharge information occurs frequently; illiteracy does not completely account for the observed low rates of recall.

Pulmonary fibrosis and lung cancer in the United States: analysis of the multiple cause of death mortality data, 1979 through 1991.

Abstract: We determined the relationship between pulmonary fibrosis and lung cancer in the United States from 1979 through 1991 by analyzing death certificate reports compiled by the National Center for Health Statistics Of the 26,866,600 people who died during the study period, 107,312 died with pulmonary fibrosis, 1,739,725 died with lung cancer, 2,040,634 died with chronic obstructive pulmonary disease, and 7,807 died with asbestosis Lung cancer occurred less frequently among decedents with pulmonary fibrosis (481%) and more frequently among decedents with chronic obstructive pulmonary disease (1006%) and decedents with asbestosis (2660%) than among decedents in the general population (648%) We conclude that the prevalence of lung cancer among people who died with a diagnosis of pulmonary fibrosis is lower than the 10% to 40% prevalence that has been reported in case series of pulmonary fibrosis

Cyclophosphamide in the treatment of toxic epidermal necrolysis

Abstract: A patient with non-small cell lung carcinoma and recent radiotherapy for brain metastases developed toxic epidermal necrolysis (TEN) shortly after therapy with phenytoin was initiated for a seizure. Exfoliation progressed to involve 90% of her body surface despite treatment with high-dose corticosteroids for 5 days, but sloughing and systemic toxicity ceased within 2 days of initiating therapy with intravenous cyclophosphamide (300 mg/day). Reepithelialization rapidly followed. This experience and the reports of others suggest that intravenous cyclophosphamide is helpful in the treatment of TEN.

Clinical and imaging features of pulmonary strongyloidiasis.

Abstract: We evaluated 20 patients with pulmonary strongyloidiasis for risk factors, clinical and imaging manifestations, complications, treatment, and outcome. Eighteen (90%) had risk factors for strongyloidiasis including steroid use, age greater than 65, chronic lung disease, use of histamine blockers, or chronic debilitating illness. Pulmonary signs and symptoms, including cough, shortness of breath, wheezing, and hemoptysis, were present in 19 (95%); adult respiratory distress syndrome (ARDS) developed in 9 (45%). Pulmonary infiltrates occurred in 18 (90%). Gastrointestinal signs and symptoms were also common. Peripheral blood eosinophilia occurred in 15 (75%). Twelve (60%) had secondary infection, and 3 (15%) had bacterial lung abscesses. All were treated with thiabendazole, 25 mg/kg twice daily; on average, patients without ARDS were treated for 3 days, versus 7 days for those with ARDS. Seventy percent responded to therapy; 30% died. Preexisting chronic lung disease and ARDS were statistically significant predictors of a poor prognosis.

Superior mesenteric artery syndrome in an intravenous drug abuser after rapid weight loss.

Abstract: Superior mesenteric artery (SMA) syndrome is a form of small-bowel obstruction due to vascular compression of the duodenum. We describe a case of SMA syndrome in an intravenous drug abuser who had rapid weight loss during a 2-week drug binge. Radiographic studies are necessary to confirm the diagnosis, and our case illustrates the value of computed tomography in diagnosing this relatively rare but serious disorder. The management of this syndrome requires reversing or removing the precipitating factors as well as correcting any secondary complications. Increased awareness of this condition may result in improved recognition and timely management of this rare cause of high intestinal obstruction, thus reducing its potential morbidity and complications.

Primary small cell undifferentiated carcinoma of the rectum associated with ulcerative colitis.

Abstract: Primary small cell undifferentiated carcinomas (SCUCs) are unusual tumors of the colon and rectum. Histologically, these lesions represent a spectrum of neuroendocrine differentiation, with oat cell carcinoma being the most primitive subtype and carcinoid tumors being the most differentiated. This observation is supported by immunohistochemical and ultrastructural findings. We report a case of SCUC of the rectum in a patient with ulcerative colitis. To date, there have been only two reported cases of primary SCUC associated with ulcerative colitis. Recent theories of tumorigenesis attribute most colorectal cancers to a single, pluripotential mucosal stem cell, regardless of the tumor's histologic type.

Ingestion of angel's trumpet: an increasingly common source of toxicity.

Abstract: Angel's trumpet is a hallucinogenic plant commonly cultivated as an ornamental in the southeastern United States. Consumption of any part of the plant may result in severe anticholinergic toxicity. In past years, toxicity has largely resulted from accidental ingestion, but in 1994 there was a ten-fold increase in the number of reported ingestions throughout the state of Florida, largely by persons experimenting with the plant for its hallucinogenic effects. We report three such cases and review the literature on diagnosis, treatment, and sequelae of angel's trumpet intoxication.

EMLA cream as a topical anesthetic before office phlebotomy in children.

Abstract: We studied the effectiveness of EMLA cream (2.5% lidocaine, 2.5% prilocaine) in reducing distress, anxiety, and pain associated with phlebotomy in pediatric outpatients. This was a randomized, double-blind, placebo-controlled study using EMLA cream or placebo 1 hour before phlebotomy. Distress, anticipatory anxiety, pain, and adverse reactions were measured. Measurements of distress and ease of procedure, as well as changes in heart rate, showed significant improvement with EMLA cream as compared with placebo. Pain was decreased with use of EMLA cream. Anticipatory anxiety levels were equal within both groups. Ratings of cream efficacy by parent/observer scales were in favor of EMLA cream.

Marjolin's ulcer of the foot caused by nonburn trauma.

Abstract: Marjolin's ulcers are malignancies that arise from previously traumatized, chronically inflamed, or scarred skin. We report a case of squamous cell carcinoma arising in a foot wound 42 years after the time of injury. The historical background, epidemiology, pathophysiology, diagnosis, treatment, and prognosis of Marjolin's ulcer are reviewed. Diagnosis is best accomplished by punch biopsy or excision of suggestive lesions. Wide local excision is required and amputation may be necessary to achieve an adequate margin. Regional lymph node dissection should be done if regional nodes are palpable. Elective lymph node dissection is controversial but should be considered if the tumor is poorly differentiated. Lymph node metastases and high tumor grade indicate a poor prognosis. Clinicians should be diligent in the long-term surveillance of all significant scars or areas of chronic inflammation.

Significance of chest trauma in children

Abstract: Chest trauma in children is a marker of injury severity and is associated with a high mortality rate. This retrospective study of 1,356 trauma patients from a private pediatric hospital over a 2.5-year period identified 82 patients with chest injuries and a mortality rate of 22%. Results of Injury Severity Score, Glasgow Coma Scale, and Revised Trauma Score all indicated that children with chest injuries sustained more severe injuries. The presence of any extrathoracic injury was associated with a higher mortality (29%) than chest injury alone (4.3%). The type of extrathoracic injury was important, with head and neck injuries resulting in the highest mortality. Specific chest injuries, such as rib fractures and pulmonary contusions, were not related to increased mortality unless there was an associated extrathoracic injury. Many reports have shown a high mortality associated with chest trauma. This study suggests that it is the associated extrathoracic injury, rather than the chest injury itself, that is the real cause of the high mortality. Language: en

A whiff of death: fatal volatile solvent inhalation abuse.

Abstract: Inhalation abuse of volatile solvents, previously known generically as "glue sniffing," is typically pursued by adolescents. A wide range of legal, easily obtained products containing volatile substances are available for abuse. We report two illustrative cases of fatal volatile substance abuse: gasoline sniffing in a 20-year-old man and aerosol propellant gas inhalation (aerosol air freshener) in a 16-year-old girl with underlying reactive airway disease. Although the ratio of deaths to nonfatal inhalation escapades is extremely low, volatile solvent abuse carries the risk of sudden death due to cardiac arrest after a dysrhythmia or vasovagal event, central nervous system respiratory depression, hypoxia and hypercapnia due to the techniques of inhalation, and other mechanisms. Investigation of the patient's substance abuse history, examination of the scene of death, and special toxicologic analyses are critical to identifying volatile substance inhalation abuse as the cause of death because anatomic autopsy findings will typically be nonspecific. Above all, physicians must suspect the diagnosis of volatile substance inhalation abuse, especially in any case of sudden death involving an otherwise healthy young person.

Established adult respiratory distress syndrome successfully treated with corticosteroids.

Abstract: In 1990, we described the treatment of established adult respiratory distress syndrome (ARDS) with a sustained course of adrenocortical steroids (ACS). This report updates our experience with an uncontrolled prospective series. Patients with ARDS of more than 3 days' duration were initially given ACS in intravenous dosages of 125 to 250 mg every 6 hours, with tapering every 3 to 4 days. ARDS was present for 3 to 40 days before treatment. The PO2/FIO2 ranged from 45 to 211 (mean, 109) and the injury index from 2 to 4 (mean, 3.25). Nineteen gallium Ga 67 citrate lung scans were obtained in 18 patients. The scans showed diffuse abnormality in all 19 studies, but added no new diagnostic information. We have treated 26 patients, and overall survival was 81% (21/26). When complicating features were present, survival was 64% (9/14). Our uncontrolled, observational experience in treating established ARDS suggests that a sustained course of ACS may improve survival in these severely ill patients.

Sleep quality and physical and social well-being in North American petrochemical shift workers.

Abstract: :We modified a European questionnaire, the Standard Shiftwork Index, in syntax and length for application to workers of an American continuous operations petrochemical company in southeast Texas. Three groups of male employees—147 day workers, 107 8-hour backward rotating shift workers, and

Borderline Personality Disorder and Health Care Utilization in a Primary Care Setting

Abstract: :We examined health care utilization by subjects with symptoms of borderline personality disorder. The study included 194 female subjects between the ages of 17 and 52 who were consecutively seen for nonemergency medical care in a health maintenance organization. Each subject completed the b

Human adjuvant disease: presentation as a multiple sclerosis-like syndrome.

Abstract: :Twenty-six women had a systemic disease with central nervous system (CNS) involvement at a mean age of 39.2 years (range, 23 to 64 years) after receiving silicone breast implants (n=25) or silicone fluid injections into breasts (n=1). The median latency period between breast surgery and ons

Primary squamous cell carcinoma of the breast

Abstract: Primary squamous cell carcinoma of the breast is a rare cancer. Published reports of prognosis are variable, and most studies are case reports of one or a few patients. We report an additional case of squamous cell carcinoma of the breast occurring in a 53-year-old black woman. In reviewing the reported cases of this tumor over the past 20 years, we compared features of this cancer with those of the more common breast adenocarcinoma with squamous metaplasia. When squamous cell carcinoma of the breast is encountered, a skin primary lesion and metastasis from a distant site should be excluded. Prognosis is determined largely by stage and does not differ significantly from the prognosis in breast adenocarcinoma with squamous metaplasia.

Does hemodilution exist : effects of saline infusion on hematologic parameters in euvolemic subjects

Abstract: The effects of intravenous fluids on hematocrit are debated. We sought to determine whether maintenance or bolus fluid therapy causes a significant change in the hematocrit and other hematologic parameters included in the complete blood count. Nine subjects completed a randomized three-period crossover designed trial in which they were given no fluid, maintenance fluid, or a bolus of fluid followed by maintenance fluid. We measured complete blood counts at baseline, 1 hour, 4 hours, and 8 hours. In the bolus fluid trial, the hemoglobin and hematocrit values (mean +/- SEM) decreased by a maximum of 1.5 +/- 0.1 g/dL and 4.1 +/- 0.3% at 1 hour. There was no difference in hemoglobin or hematocrit during the no fluid or maintenance fluid treatments. No significant changes occurred in white blood cell or platelet counts. We demonstrated that maintenance fluid infusions do not significantly after the complete blood count. Saline bolus is associated with a significant decrease in hemoglobin and hematocrit, but these parameters trend toward baseline over time.

Persistent cutaneous larva migrans due to ancylostoma species

Abstract: Cutaneous larva migrans is considered to be a self-limited parasitic infection of about 2 to 8 weeks' duration, though it has been reported to persist for as long as 55 weeks. In this case, a healthy 47-year-old white man had multiple serpiginous lesions typical of cutaneous larva migrans for 18 mon

Screening for fever in an adult emergency department: oral vs tympanic thermometry.

Abstract: The accuracy of tympanic thermometers in clinical practice continues to be questioned. We evaluated the Genius tympanic thermometer in our adult emergency department. All patients had both tympanic and oral temperature measurements. Patients with an oral or tympanic temperature > or = 100.0 degrees F had a rectal temperature taken. Oral and rectal measurements were taken with the IVAC 2080A electronic thermometer, and the Genius thermometer was used in the oral equivalent mode. All instruments were calibrated. Of the 332 patients entered into the study, 51 had oral or tympanic temperatures > or = 100.0 degrees F. Forty-one of these patients consented to a rectal temperature measurement. The correlation (r) between tympanic and oral, tympanic and rectal, and oral and rectal temperature was .845, .853, and .940, respectively. The oral thermometer identified all 28 febrile patients (rectal temperature > or = 100.4 degrees F). However, the tympanic thermometer detected fever in only 19 of these cases. Two patients in whom the tympanic thermometer failed to detect fever had AIDS, and their workup was altered by the detection of the fever. We conclude that the tympanic thermometer is not as sensitive as the oral thermometer in the detection of fever. The use of tympanic thermometers in the adult emergency department should be questioned.

Dilemmas and solutions for the pathologist and clinician encountering religious views of the autopsy.

Abstract: Religious objections to the autopsy are as old as autopsies themselves. The development of anatomic studies was hindered in ancient eras, as well as in more recent times, by spiritual views occasionally hostile to the opening of bodies. This review addresses historical and recent attitudes of the three major monotheistic faiths--Judaism, Christianity, and Islam--toward postmortem examinations. Two case examples will illustrate that in many clinical scenarios in which an autopsy is desired or warranted but met with initial resistance by loved ones, a combination of patience and learned communication can pave the way to a family's understanding and acceptance of the procedure.

Intravenous Amiodarone for Therapy of Atrial Fibrillation and Flutter in Critically Ill Patients With Severely Depressed Left Ventricular Function

Abstract: :A retrospective review was done to determine the efficacy and hemodynamic effects of slow intravenous amiodarone administration on invasively monitored patients with acute onset of atrial fibrillation or atrial flutter and left ventricular ejection fractions <15%. Eight patients met predefi

Physical and sexual abuse in a middle-class obstetric population.

Abstract: This study evaluates and characterizes the prevalence and nature of physical and sexual abuse among pregnant economically stable middle-class women with access to comprehensive health care. Self-report questionnaires were distributed to 829 pregnant women who attended the prenatal orientation at Wilford Hall Medical Center from October 19 1992 to March 15 1993. Out of the 563 women (68%) who completed the surveys 100 women (18%) reported a history of physical and sexual abuse. The lifetime prevalence of physical abuse was 12% (n = 68) and the lifetime prevalence of sexual abuse was 9% (n = 51). Women who experienced physical abuse often cited an intimate partner as the assailant (5.5%) and reported more than one abusive episode. Injuries are most commonly inflicted to the head and body. Only 1% (n = 7) of the respondents claimed of being physically abused during pregnancy. Majority of these women reported being more physically (46%) rather than sexually (13%) abused by their partner. The findings indicate that health care practitioners may provide resources for counseling and support to women who are victims of physical or sexual abuse in order to reduce the long-term emotional psychological and physical sequelae of the abuse.

Decreasing length of hospital stay by early excision and grafting of burns.

Abstract: All acutely burned patients admitted to one surgeon's practice during a 1-year period were considered for burn excision and grafting. A total of 222 patients were enrolled; 57 did not have surgery. In all, 130 patients having surgery within 24 hours after admission were compared with 48 patients hav

Abdominal wall reconstruction after temporary abdominal wall closure in trauma patients

Abstract: We retrospectively analyzed 36 patients requiring temporary abdominal wall closure on admission to a level I trauma center from 1988 to 1992. There were 10 deaths (28%) in the study population. Of the 26 survivors, 8 patients (31%) had primary fascial closure at initial hospitalization, whereas 18 patients (69%) required split-thickness skin grafting to visceral granulation tissue. Of these 18 patients, 13 have had ventral herniorrhaphy at subsequent admission. Eight of these patients had primary fascial closure, 4 required primary fascial approximation with prosthetic onlay reinforcement, and 1 required multiple operations including prosthetic reconstruction and eventual complex tissue transfer. Complications occurred in 3 patients (14%) and included two wound seromas, which were drained nonoperatively, and a wound infection necessitating removal of prosthetic material and subsequent reconstruction with complex tissue transfer. Follow-up reveals no recurrent hernia at 24 months. Abdominal wall reconstruction after temporary closure can be done safely and promptly, with good functional and esthetic results.

Eye patch treatment for the pain of corneal abrasion.

Abstract: The traditional use of patching and topical antibiotics in the treatment of corneal abrasion has recently been challenged, particularly after foreign body removal. In a prospective, controlled, randomized study of 33 patients treated in the emergency department for eye pain and corneal abrasion, we attempted to determine whether eye patching affected the pain of simple corneal abrasions. After fluorescein examination with magnification (x 5), a visual analog pain score was recorded and the patient was randomized to either the patched or nonpatched group. A standard analgesic was supplied, and all patients had follow-up at 24 hours, when repeat pain scores and analgesic use were recorded. The groups were compared by using the Wilcoxon's rank sum test, Student's t test, and analysis of covariance as required. There was no significant difference in the mean changes in pain scores between the patched and nonpatched groups. Analgesic use was also similar. We conclude that routine eye patching does not favorably affect the pain associated with the treatment of simple corneal abrasion.