Showing papers in "Southern Medical Journal in 2001"

Magnesium: its proven and potential clinical significance.

Abstract: Magnesium is the fourth most abundant cation in the body and is present in more than 300 enzymatic systems, where it is crucial for adenosine triphosphate (ATP) metabolism. Deficiency states result in increased insulin resistance, as well as increased smooth muscle and platelet reactivity. Magnesium deficiency has been shown to correlate with a number of chronic cardiovascular diseases, including hypertension, diabetes mellitus, and hyperlipidemia. Intravenous magnesium has been used therapeutically in critical situations such as status asthmaticus, torsades de pointes, and preeclampsia. Few controlled studies exist regarding the therapeutic uses of oral magnesium supplementation in chronic cardiovascular diseases. Randomized clinical trials are urgently needed to determine whether magnesium supplementation will alter the natural history of these disease states.

Plasma elimination of cardiac troponin I in end-stage renal disease.

Abstract: Background. We retrospectively compared the decline of cardiac troponin I after acute myocardial infarction (AMI) in patients with normal renal function and those with end-stage renal disease (ESRD) who were receiving hemodialysis. Methods. We reviewed 257 cases with a discharge diagnosis of AMI or AMI plus ESRD; 222 were excluded due to inadequate data or evidence of ongoing myocardial necrosis. Decline of cardiac troponin I values was followed over a mean (± SD) of 2.75 ± 1.2 days in patients with normal renal function and 2.7 ± 2.0 days in ESRD patients. Average apparent half-life and apparent elimination rate constant of troponin I were compared between groups. Results. Of 35 patients with AMI, 16 had ESRD and were receiving hemodialysis, and 19 had normal renal function. Mean (± SD) apparent half-lives of troponin I in the ESRD group and the group with normal renal function were 1.48 ± 0.77 days and 1.08 ± 0.63 days, respectively. The mean apparent elimination rate constants of cardiac troponin I were 0.64 ± 0.33 days -1 in the ESRD group and 0.91 ± 0.55 days -1 in the group with normal renal function. Conclusion. The difference in apparent half-life and apparent elimination rate constant of cardiac troponin I between patients with normal renal function and those with ESRD is not statistically significant.

New polyethylene glycol laxative for treatment of constipation in adults: a randomized, double-blind, placebo-controlled study.

Abstract: Background.This study evaluated the safety and effectiveness of a new polyethylene glycol (PEG) laxative (MiraLax, Braintree Laboratories Inc, Braintree, Mass) in 23 patients reporting a history of constipation.Methods.After a 7-day placebo control period, patients were randomized into a dou

Effect of literacy on breast-feeding outcomes.

Abstract: Background.We studied the effect of functional health literacy on the initiation and continuance of breast-feeding in women at a public health clinic.Methods.Subjects were 61 first-time mothers aged 18 years or older who spoke English as their first language. They were divided into two group

Randomized, double-blind, placebo-controlled trial of coenzyme Q10 in isolated systolic hypertension.

Abstract: Background Increasing numbers of the adult population are using alternative or complementary health resources in the treatment of chronic medical conditions. Systemic hypertension affects more than 50 million adults and is one of the most common risk factors for cardiovascular morbidity and mortality. This study evaluates the antihypertensive effectiveness of oral coenzyme Q10 (CoQ), an over-the-counter nutritional supplement, in a cohort of 46 men and 37 women with isolated systolic hypertension. Methods We conducted a 12-week randomized, double-blind, placebo-controlled trial with twice daily administration of 60 mg of oral CoQ and determination of plasma CoQ levels before and after the 12 weeks of treatment. Results The mean reduction in systolic blood pressure of the CoQ-treated group was 17.8 +/- 7.3 mm Hg (mean +/- SEM). None of the patients exhibited orthostatic blood pressure changes. Conclusions Our results suggest CoQ may be safely offered to hypertensive patients as an alternative treatment option.

Psoas abscess: a primer for the internist.

Abstract: Psoas abscess is a rare condition with vague clinical presentation. In this article, its epidemiology, etiology, bacteriology, diagnosis, and treatment are discussed. Common diseases that may be erroneously diagnosed in patients with psoas abscess are presented.

Practical issues in the management of hypersensitivity reactions: sulfonamides.

Abstract: Approximately 3% of the general population and 60% of patients with human immunodeficiency virus (HIV) infection have adverse reactions when treated with sulfonamide antimicrobials. The most common clinical manifestations of sulfonamide hypersensitivity are fever and a maculopapular rash 7 to 14 days after initiating therapy, though a variety of more severe manifestations may occur. The sulfonamide chemical moiety is present in many medications that are not antimicrobials, and fortunately hypersensitivity reactions to these medications are less common. The immunogenicity of sulfonamide antimicrobials may be due to the presence of an arylamine group at the N4 position of the sulfonamide molecule. No diagnostic tests are available to confirm sulfonamide hypersensitivity, and while avoidance of the drug is generally appropriate when a previous hypersensitivity reaction is suspected, desensitization protocols are available for use in HIV patients in whom Pneumocystis carinii pneumonia prophylaxis or treatment is indicated.

Secondary prevention of cerebral ischemia in patent foramen ovale: systematic review and meta-analysis.

Abstract: Background Therapy for patent foramen ovale (PFO), found with increased frequency in the setting of stroke in the young, is controversial. We compiled a synthesis of the literature on therapeutic options for PFO and stroke. Methods Searching MEDLINE (1966 to 1999), published abstracts, and bibliographies of primary and review articles, we identified five retrospective cohort studies that compared at least two different treatment options (antiplatelet therapy, warfarin, or surgery). Outcomes data on mode of therapy and recurrent stroke were abstracted, and pooled analysis was done using a random effects model. Results Warfarin was superior to antiplatelet therapy in preventing recurrent ischemic events (odds ratio [OR] 0.37; 95% confidence interval [CI], 0.23 to 0.60). Surgical PFO closure was comparable to warfarin treatment (OR 1.19; 95% CI, 0.62 to 2.27). Conclusion Available data suggest that warfarin is superior to antiplatelet therapy and comparable to surgical PFO closure for the prevention of recurrent cerebral ischemic events from paradoxical embolism.

Religion in the clinic: the role of physician beliefs.

Abstract: Background.Although studies have identified physician beliefs that may cause them to avoid spiritual topics in the clinic (eg, lack of time), it is unknown to what extent these beliefs predict behavior. The purpose of the present study was to identify physician beliefs about religion and med

Stroke awareness among Georgia adults: epidemiology and considerations regarding measurement.

Abstract: Background. To design and evaluate interventions for reducing the impact of stroke in Georgia, we assessed knowledge of signs, risk factors, and burden of stroke. Methods. Adults in Georgia were studied with a random digit dial telephone survey. Results. Answering an unaided question, 39% of 602 respondents named ≥1 stroke warning sign. Awareness was considerably greater when assessed with prompted questions. Most respondents (70%) said they would call 911 if someone had a stroke; almost all (95%) considered stroke an emergency. Risk factor awareness ranged from 97% (previous stroke) to 69% (diabetes). Altogether, 6% reported having had a stroke; 48% reported a stroke in their family. Conclusions. Georgia adults have low awareness of stroke warning signs. Our findings underscore the importance of conducting an effective educational campaign. Furthermore, a need exists for questions on stroke awareness that approximate more closely the situation in which a person must identify a potential stroke.

Effects of antimanic mood-stabilizing drugs on fetuses, neonates, and nursing infants.

Abstract: Pregnancy presents a special problem to the clinician treating bipolar disorders in women. Since the first episode of mania typically occurs before the age of 30, many women in their prime childbearing years may be exposed to potentially teratogenic mood-stabilizing agents. This exposure may also continue for the nursing infant during lactation. Pregnancy itself can exacerbate bipolar symptoms and also alter the pharmacokinetics of mood-stabilizing drugs. Risks to mother and fetus can be reduced with a number of simple strategies, including monotherapy with the lowest effective dose of a drug for the shortest period necessary, periconceptional use of multivitamins with folate, prescription of drugs with established safety records, and avoidance of exposure to antimanic agents during the first trimester of pregnancy. In this article, we review existing evidence on the risks to fetuses and nursing infants of mothers taking specific mood-stabilizing agents, and we present appropriate management guidelines designed to minimize these risks.

Outbreak of Salmonella serotype Anatum infection associated with unpasteurized orange juice.

Abstract: In March 1999, a patient was infected with Salmonella serotype Anatum after having consumed unpasteurized orange juice from a manufacturer in Florida. We conducted a cohort study among customers of the manufacturer, performed pulsed-field gel electrophoresis (PFGE) on isolates, and inspected the manufacturing plant. Surveillance data identified three additional patients infected with Salmonella Anatum showing indistinguishable or closely related PFGE patterns. Three of the four patients had consumed orange juice from the same manufacturer. In the cohort study, 6 of 68 persons (9%) who consumed orange juice and/or orange ice cream from the manufacturer were ill, compared with 1 of 47 (2%) who did not. A positive antigen test for Salmonella species and coliform growth in juice samples taken from the production line suggested contamination during the manufacturing process. Commercially produced orange juice should be pasteurized or otherwise processed to achieve equivalent reduction of pathogens.

Human immunodeficiency virus infection in elderly patients

Abstract: Background. The proportion of older individuals infected with the human immunodeficiency virus (HIV) is rising. Methods. We performed a retrospective case-control study of 58 patients more than 60 years old at the time of diagnosis of HIV infection and compared them with 232 controls (matched by CD4 + lymphocyte count). Clinical and demographic data were obtained from the Adult Spectrum of Diseases (ASD) database at the Medical Center of Louisiana, Results. Patients in the older age group were more likely to be male and African American or Hispanic. The most common risk factor for acquisition of HIV infection among the patients was homosexual contact (53%). Disease staging was similar in both groups as determined by CD4 + lymphocyte counts and history of opportunistic infections. There was no difference in the use of antiretroviral therapy. In a Cox proportional hazard model and regression models, age ≥60 years was associated with shorter survival. Conclusion. Patients who are older than 60 years at the time of diagnosis of HIV infection have a shorter survival than younger patients.

Comorbid Illness and the Early Detection of Cancer

Abstract: Background. Comorbidity may be associated with later detection of cancer. Methods. Incident cases of colorectal, breast, and prostate cancer and melanoma were determined from the 1994 Florida state tumor registry (N = 32,074). The relationship between comorbidity and late stage at diagnosis was examined using multiple logistic regression. Results. Patients with comorbid conditions had greater odds of late stage diagnosis for each of the four cancers (colorectal, melanoma, breast, and prostate). Higher mortality rates were observed among patients with comorbid illness, not as a result of later stage at diagnosis, but rather due to their underlying disease. Conclusions. Comorbidity was associated with later stage diagnosis. Further research is needed to determine mechanisms by which comorbidity might influence stage at diagnosis.

Perforated Amyand's hernia.

Abstract: We report a case of acute perforated appendicitis in an incarcerated inguinal hernia, termed an Amyand's hernia. Although perforated appendicitis within an incarcerated inguinal hernia is uncommon, with a published incidence of 0.13%, its clinical presentation varies considerably, depending on the extent of periappendicular inflammation and the presence or absence of peritoneal contamination.

Anal melanoma: an aggressive malignancy masquerading as hemorrhoids.

Abstract: Anal melanoma is a devastating malignancy easily confused with benign hemorrhoids. Physician unfamiliarity with this bleeding rectal lesion can lead to delays in diagnosis and therapy. Four cases of anal melanoma, all initially mistaken for hemorrhoids, have been documented in the past 4 years at our institution. Despite surgical intervention and chemoimmunotherapy, each patient succumbed to widely metastatic disease. Average survival was 15.2 months. The clinical, pathologic, surgical, and oncologic features of anal melanoma are reviewed to enhance physician recognition of this unusual anorectal disorder.

Eye symptoms and use of eye protection among seasonal and migrant farmworkers

Abstract: Background. Farmworkers face an array of environmental and workplace hazards that pose risks of eye damage from accidents involving agricultural chemicals and equipment and from exposure to wind, dust, and ultraviolet rays. Eye safety risks are known among industrial and agricultural occupations, yet little is known about the prevalence of eye symptoms and use of eye protection among farmworkers. Methods. A survey of 197 Latino farmworkers in North Carolina used self-report data to measure workers' prevalence of eye symptoms and eye protection use. Results. Eye pain and redness after working all day in the field were reported by more than 40% of workers. Most (98.4%) reported not wearing sunglasses when working in the fields; reasons included lack of sunglasses and interference with field tasks. Conclusions. Eye symptoms are prevalent in this population. Failure to use eye protection indicates the need for further education and training of Latino farmworkers and their employers about occupational risks to eyesight.

Generic substitution: issues for problematic drugs.

Abstract: The methodology and criteria for bioequivalence testing have been firmly established by the Food and Drug Administration (FDA). For certain drugs with a narrow therapeutic index (e.g., digoxin, levothyroxine, warfarin), generic substitution may not be advisable or even allowable, depending on the substitution laws of individual states. Digoxin and levothyroxine tablets are examples of drugs for which no New Drug Applications (NDAs) currently exist. However, commercially available generic products for both of these drugs have not been determined by the FDA to be therapeutically equivalent to the innovator products. Generic versions of warfarin have been approved by the FDA as being therapeutically equivalent to the innovator products, as have generic versions of the rescue inhaler albuterol. Yet, misinformation and myths persist regarding the adequacy and proven reliability of the FDA's determination of bioequivalence for these products.

Antibiotic prescribing practices in a teaching clinic: comparison of resident and staff physicians.

Abstract: BACKGROUND: The widespread and often inappropriate use of broad spectrum antibiotics in the outpatient setting is recognized as a significant contributing factor to the spread of bacterial resistance. We hypothesized that residents prescribe broader spectrum antibiotics more frequently than staff physicians and adopt more appropriate prescribing practices with increasing levels of training. METHODS: All patient visits for acute sinusitis in our teaching practice between July 1, 1995, and June 30, 1997, were reviewed. Comparisons of antibiotics prescribed were made between staff and residents at each level of training. RESULTS: First- and second-year residents were more likely to prescribe narrow spectrum antibiotics (56%) than third-year residents (35%) or staff (34%). CONCLUSIONS: Junior residents in our program are more likely to prescribe narrow spectrum antibiotics for the treatment of acute sinusitis than are senior residents or staff. With advancement in level of training, prescribing practices of residents come to resemble those of their supervising staff physicians.

Streptococcus agalactiae endocarditis and giant pyomyoma simulating ovarian cancer.

Abstract: Group B streptococcus (Streptococcus agalactiae) is a common etiology of bacteremia among adults Pyomyoma is a rare infectious complication of uterine leiomyomas We report the case of a diabetic postmenopausal woman with a giant pyomyoma simulating an ovarian cancer It was associated with S agalactiae endocarditis and deep venous thrombosis of the right external iliac and femoral veins Treated initially with intravenous penicillin, amikacin, and anticoagulation, the patient later had abdominal hysterectomy with an uneventful recovery We also review the cases of pyomyoma reported since 1945 Of 14 cases described (including ours), mortality was 21% Endocarditis was never reported in association with pyomyoma The presence of bacteremia and a leiomyoma should raise suspicion for this disease

Importance of postprandial glucose control.

Abstract: Although a traditional goal of glycemic control in the treatment of diabetes mellitus is to normalize fasting plasma glucose, emerging data indicate that modulation of postprandial plasma glucose levels plays an important role in overall glycemic control. This article reviews the evidence linking postprandial glucose levels with long-term indices of diabetes control, such as glycosylated hemoglobin, lipid abnormalities, and the risk of microvascular and macrovascular complications. Early in the development of type 2 diabetes, the initial burst of insulin release in response to food intake is compromised, allowing postprandial hyperglycemia to develop. Meal-associated hyperglycemia further contributes to increase insulin resistance and decrease insulin production. Evidence of a strong correlation between high postprandial glycemic levels and the development of vascular complications underscores the significance of treating mealtime glycemia. Emerging drugs that reduce postprandial hyperglycemia include the D-phenylalanine derivative nateglinide, amylin derivative pramlintide, and glucagon-like insulinotropic peptide.

Acupuncture for chronic low back pain: diagnosis and treatment patterns among acupuncturists evaluating the same patient.

Abstract: Background.There is increasing need to examine the effectiveness of acupuncture and other alternative therapies for common conditions. However, little attention has focused on the variability in acupuncturists' assessment, diagnosis, and treatment patterns.Methods.Seven office-based acupunct

Delayed diagnosis of intracranial aneurysms: confounding factors in clinical presentation and the influence of misdiagnosis on outcome.

Abstract: The initial presentation of intracranial aneurysm can be missed in routine clinical practice. An underlying aneurysm may have a subtle presentation that warrants definitive diagnostic procedures. A retrospective review of 270 patients with aneurysms at our institution revealed 40 patients (14.8%) with a significant delay in diagnosis before definitive treatment. The delay due to missed diagnosis varied from 2 days to a few months. In retrospect, 58% had a Hunt and Hess grade I clinical presentation at readmission. Clinical status was rated as grade 0-I in the majority of patients (65%), grade II in 20%, and grade III in 12.5%. One patient had grade IV status. These grades are significantly different from the initial grade at which each of the patients first sought medical attention. The second admission significantly affected the outcome. A delay in diagnosis of aneurysmal subarachnoid hemorrhage resulting in poor clinical grade influenced neurologic outcome significantly.

Polycystic ovary syndrome: new perspective on an old problem.

Abstract: Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in women of reproductive age. New treatment approaches resulting from a refined understanding of the pathophysiology are evolving. The literature shows that PCOS is an endocrinopathy resulting from insulin resistance and the compensatory hyperinsulinemia. This results in adverse effects on multiple organ systems and may result in alteration in serum lipids, anovulation, abnormal uterine bleeding, and infertility. In addition, PCOS may place the patient at long-term risk for the development of type 2 diabetes, hypertension, endometrial cancer, and cardiovascular disease. Oral contraceptives, progestins, antiandrogens, and ovulation induction agents remain standard therapies. However, insulin-sensitizing agents are now being shown to be useful alone or combined with standard therapies. Early identification of patients at risk and prompt initiation of therapies, followed by long-term surveillance and management, may promote the patient's long-term health.

Pulmonary hypertension associated with HIV infection.

Abstract: Pulmonary hypertension occurs with increased frequency among patients with human immunodeficiency virus (HIV) infection Although the pathogenesis of HIV-associated pulmonary hypertension remains unknown, it appears to occur independently of other risk factors associated with pulmonary vasculopathy, such as chronic hepatitis C infection and intravenous drug use Signs and symptoms are typical of those immunocompetent patients with primary pulmonary hypertension, but because many HIV-infected patients are receiving intensive medical supervision, the diagnosis of pulmonary hypertension is often made at an earlier stage Acute responses to epoprostenol are similar to those among non-HIV-infected individuals, but the benefits of long-term, intravenous treatment with epoprostenol in HIV-infected patients is unknown Future investigations should define the true incidence of pulmonary hypertension and the long-term effects of epoprostenol on survival among HIV-infected individuals Physicians should be alert to possible pulmonary hypertension in persons infected with HIV

Noncompliance of health care workers with universal precautions during trauma resuscitations.

Abstract: Background Universal precautions during resuscitations are mandated by hospital regulations. We documented adherence to universal precautions during trauma resuscitations at our level I trauma center. Methods During trauma resuscitations, a medical student using an elevated viewing platform observed health care workers (HCWs) for the use of barrier precautions (BPs): gloves, masks, gowns, and eyewear. Only HCWs having direct patient contact were included. The purpose of the observation was not disclosed to those being observed. Results In 12 resuscitations involving 104 HCWs, none had 100% compliance with BPs. Compliance rates for individual BPs were gloves, 98%; eyewear (any type), 52%; gowns, 38%; masks, 10%; and eyewear (with side protectors), 9%. Resuscitations in which bleeding was observed involved 59 HCWs with 38% compliance; only 2 used full BPs. No difference in compliance rates occurred during the study period. Conclusions Experienced trauma care HCWs are cavalier regarding blood-borne disease exposure risks. Measures to encourage (or force) compliance are needed.

Use of oral creatine as an ergogenic aid for increased sports performance: perceptions of adolescent athletes.

Abstract: Background. Competitive athletes, including adolescents, seek ways to gain advantage over competitors. One ergogenic aid is creatine, a naturally occurring nitrogen compound found primarily in skeletal muscle. Increasing creatine levels may prolong skeletal muscle activity, enhancing work output. Methods. A questionnaire assessing awareness and use of creatine supplementation was completed by 674 athletes from 11 high schools. Data were statistically analyzed to determine variation among groups. Results. Of those surveyed, 75% had knowledge of creatine supplements, and 16% used creatine to enhance athletic performance. Percentage of use increased with age and grade level. Awareness and use were greater among boys than girls. Adverse effects were reported by 26%. Most athletes consumed creatine using a method inconsistent with scientific recommendations. Conclusions. Use of creatine by adolescent athletes is significant and inconsistent with optimal dosing. Physicians, athletic trainers, and coaches should disseminate proper information and advise these adolescent athletes.

Acupuncture in an outpatient clinic in China: a comparison with the use of acupuncture in North America.

Abstract: Background The National Institutes of Health Consensus Panel on Acupuncture has listed as a priority the study comparing indications and patterns of use of acupuncture in different countries. Methods I visited an outpatient acupuncture clinic in China and reviewed the clinical files. A MEDLINE search was done to compare the use of acupuncture in North America and China. Results The most common disorder treated in the clinic was musculoskeletal pain. Less common indications included stroke rehabilitation, Bell's palsy, cholelithiasis, tinnitus, insomnia, migraine, and visceral pain. In North America, acupuncture is primarily for pain relief. Other uses include stroke rehabilitation, various emetic problems, migraine, and various addictions. Conclusions Acupuncture is most frequently used in China and North America for pain relief. Other common indications include peripheral nerve palsy, peripheral nerve neuralgia, stroke rehabilitation, psychoemotional disorders, migraine, visceral pain, emesis, asthma, and tinnitus. Acupuncture for cholelithiasis in China but not in the United States suggests a novel use of this modality.

Vitamin D: balancing cutaneous and systemic considerations.

Abstract: BACKGROUND: Vitamin D insufficiency may lead to various health problems. By encouraging sun protection to prevent skin cancer, physicians may be limiting a major source of vitamin D for many individuals. METHODS: We did a literature review on issues related to vitamin D inadequacy, particularly those relevant to various racial/ethnic groups. RESULTS: Vitamin D is an important hormone with many physiologic roles beyond those related to bones, including blood pressure regulation and acting as a tumor suppressant. The recommended amount of vitamin D has recently increased for adults over age 50. Moreover, some researchers are urging higher doses for the entire population to prevent osteoporotic fractures. CONCLUSIONS: Previous studies that have found serum levels of vitamin D in their sun-protected subjects to be in the normal range may need to be reevaluated. In concert with counseling sun protection, physicians should consider discussing vitamin D intake, typically in the form of supplements.