Showing papers in "Southern Medical Journal in 2004"

Religion, spirituality, and medicine: research findings and implications for clinical practice.

Abstract: A growing body of scientific research suggests connections between religion, spirituality, and both mental and physical health. The findings are particularly strong in patients with severe or chronic illnesses who are having stressful psychologic and social changes, as well as existential struggles related to meaning and purpose. Recent studies indicate that religious beliefs influence medical decisions, such as the use of chemotherapy and other life-saving treatments, and at times may conflict with medical care. This article addresses the ways physicians can use such information. Spirituality is an area that makes many physicians uncomfortable, since training in medical schools and continuing medical education programs are limited. Not only do most physicians lack the necessary training, they worry about spending additional time with patients and overstepping ethical boundaries. While these concerns are valid, each can be addressed in a sensible way. Taking a spiritual history, supporting the patient's beliefs, and orchestrating the fulfillment of spiritual needs are among the topics this article will address. The goal is to help physicians provide medical care that is sensitive to the way many patients understand and cope with medical illness.

Sedation during mechanical ventilation in infants and children: dexmedetomidine versus midazolam.

Abstract: Background:We sought to compare the efficacy of midazolam versus dexmedetomidine for sedation during mechanical ventilation in infants and children.Methods:We performed a prospective, randomized trial in a pediatric intensive care unit in a tertiary care center. Infants and children requiring mechan

Skin toxicity during breast irradiation: pathophysiology and management.

Abstract: Radiotherapy is a critical component in the treatment of breast cancer, a disease that is estimated to have affected 203,500 US women in 2002. According to the data from some series, an estimated 90% of patients treated with radiotherapy for breast cancer will develop a degree of radiation-induced dermatitis. This review describes the indications and techniques of radiotherapy for breast cancer. The pathophysiology, clinical presentation, and contributing factors of radiation-related skin injury are discussed. A review of recent clinical research addressing skin toxicity is provided.

Official positions of the International Society for Clinical Densitometry.

Abstract: The International Society for Clinical Densitometry (ISCD) has convened two Position Development Conferences at which a panel of experts agreed on recommendations for performance and clinical applications of bone density testing. These recommendation were reviewed by the ISCD Board of Directors, and those approved by the board are now official positions of the ISCD. These include (1) indications for bone density testing, (2) reference databases for T-scores, (3) standards for performing central dual-energy X-ray absorptiometry (DXA) for diagnosis, (4) interpretation of peripheral bone density results, (5) diagnosis of osteoporosis in postmenopausal women, (6) diagnosis of osteoporosis in men, (7) diagnosis in premenopausal women, (8) diagnosis in children, (9) indications and interpretation for serial bone mass measurement, (10) technical standards for phantom scanning and calibration, (11) technical standards for cross-calibration of DXA systems, and (12) standards for reporting of bone density results including correct nomenclature and preferred number of decimal digits.

Religious involvement and adult mortality in the United States: review and perspective.

Abstract: Objectives: The scientific community has recently taken a serious interest in the relation between religious involvement and adult mortality risk in the United States. We review this literature, highlighting key findings, limitations, and future challenges. Methods: Literature from medicine, epidemiology, and the social sciences is included. Results: Taken together, the existing research indicates that religious involvement is related to US adult mortality risks. The evidence is strongest for public religious attendance and across specific religious denominations. The evidence is weakest for private religious activity. The mechanisms by which religious involvement appear to influence mortality include aspects of social integration, social regulation, and psychological resources. Conclusions: The religion-mortality literature has developed in both size and quality over the past decade. Fruitful avenues for continued research include the analysis of (1) more dimensions of religious involvement, including religious life histories; (2) population subgroups, including specific race/ethnic and socioeconomic populations; and (3) a richer set of social, psychologic, and behavioral mechanisms by which religion may be related to mortality.

The role of religion/spirituality for cancer patients and their caregivers.

Abstract: Research has shown that religiosity and spirituality significantly contribute to psychosocial adjustment to cancer and its treatments. Religion offers hope to those suffering from cancer, and it has been found to have a positive effect on the quality of life of cancer patients. Numerous studies have found that religion and spirituality also provide effective coping mechanisms for patients as well as family caregivers. Research indicates that cancer patients who rely on spiritual and religious beliefs to cope with their illness are more likely to use an active coping style in which they accept their illness and try to deal with it in a positive and purposeful way. Faith-based communities also offer an essential source of social support to patients, and religious organizations can play a direct and vital role in cancer prevention by providing screening, counseling, and educational programs, especially in minority communities.

Religion and HIV: a review of the literature and clinical implications.

Abstract: Despite substantive research documenting the connection between various religious dimensions and physical and mental health, surprisingly little attention has been given to the study of religion among individuals with the human immunodeficiency virus (HIV). Although initially considered to be a white, “gay man’s” disease, today women and ethnic minorities are subgroups that are the most severely affected by the HIV pandemic. Importantly, these disenfranchised subgroups report greater use of religion in their everyday lives. A small but growing number of studies conducted mostly within the past few years have recognized the importance of religion in the lives of individuals with HIV. In particular, research has noted the frequent use of religious coping by men and women with HIV to deal with the loss of their loved ones to AIDS, to overcome their sense of guilt and shame in engaging in risky behaviors, and to find a renewed sense of purpose in life. However, clinical interventions with persons with HIV have largely neglected religiousness and spirituality as resources for treatment and, to date, few spirituality-based interventions exist that can be empirically evaluated. In this paper, we review the literature on religious coping among individuals with HIV and outline a clinical intervention that incorporates religious issues relevant to this population. We first provide an overview of religious coping.

Body weight status, dietary habits, and physical activity levels of middle school-aged children in rural Mississippi.

Abstract: Objectives:Obesity and cardiovascular diseases are more prevalent in the Southeast as compared with other geographic regions of the United States. However, few investigations have addressed health disparities among children in rural Southeastern areas. The purpose of this investigation was to determ

Spiritual care: whose job is it anyway?

Abstract: The use of spirituality and religion in coping with illness is widespread among primary care patients. Although the overwhelming majority of healthcare providers agree that they should be aware of patients' spiritual beliefs, that these beliefs may influence their healing, and that patients benefit from spiritual care, there remains considerable debate about who should inquire about spiritual beliefs and deliver spiritual care. The authors, a physician and a chaplain, propose that, in general, the role of the physician is to assess spiritual needs as they relate to healthcare (ie, briefly screen) and then refer to a professional pastoral caregiver as indicated (ie, to address those needs). The chaplain is the spiritual care specialist on the healthcare team and has the training necessary to treat spiritual distress in all its forms. Seeing the physician as the generalist in spiritual care and the chaplain as the specialist is a helpful model.

Effect of omeprazole on oral iron replacement in patients with iron deficiency anemia.

Abstract: Hypochlorhydric states such as atrophic gastritis and partial gastrectomy have long been known to cause iron deficiency anemia. However, studies to date have failed to show a similar association with omeprazole, a proton pump inhibitor that also produces achlorhydria. These studies, however, have primarily involved nonanemic, iron-replete individuals. The effect of the drug has not been studied in patients with established iron deficiency, and to our knowledge the patients presented here are the first of their kind to be reported. Our observations support the probability that the profound hypochlorhydria induced by omeprazole may indeed impair the optimal absorption of orally administered iron in iron-deficient individuals, precluding them from obtaining therapeutically adequate amounts to establish the positive balance necessary for the resolution of anemia and the replenishment of stores. The possible explanations for this phenomenon are also discussed.

Meckel diverticulum: ten-year experience in adults.

Abstract: Objectives: Meckel diverticulum, a congenital gastrointestinal anomaly, is well studied in pediatrics, but less so in the adult population. At the Charleston Area Medical Center (CAMC), in addition to the removal of Meckel diverticula in symptomatic patients, diverticula are commonly removed when found incidentally during other procedures. We present our experience over the past ten years with this condition, unusual in the adult population. Methods: From 1992 to 2002 at the Charleston Area Medical Center, Meckel diverticula were removed from 47 patients older than 18 years of age. We reviewed the age, sex, indication for removal, pathologic findings, and perioperative complications of these cases. Results: Diverticula were removed most often from female patients (31 female, 66%; 16 male, 34%). The removal of the diverticulum was incidental in 35 patients (74.5%) and symptomatic in 12 (25.5% percent). Symptomatic patients presented with: obstruction (n = 4), acute bleeding (n = 1) and diverticulitis (n = 7). Female patients were significantly less likely than male patients to be symptomatic (4 of 31, 13% among females, and 8 of 16, 50% among males; P < 0.05). Heterotopic mucosa was identified in six patients, two of whom were symptomatic at the time of removal. Gastric mucosa was found in all six of the diverticula with ectopic mucosa, although one of the six had a mixed gastric and pancreatic cell population. One asymptomatic patient had a malignancy identified as a 1.5 cm carcinoid with no evidence of metastatic disease. An adenomyoma was found incidentally in one patient upon pathologic evaluation. Hospital complications that could possibly be attributed to removal of diverticula included two wound infections and two anastomotic leaks requiring exploration (8.5% morbidity). Complications were experienced by two asymptomatic females, one asymptomatic male, and a symptomatic male. There were no mortalities. Conclusions: Meckel diverticulum is found infrequently in the adult population. Adults rarely become symptomatic, but symptoms that do arise are associated with significant morbidity. Complications directly attributable to diverticulum removal are uncommon; however, those that do occur are often life threatening. Therefore, incidental removal of asymptomatic diverticula, particularly in women, is not recommended.

Incidence of constipation associated with long-acting opioid therapy: a comparative study.

Abstract: Background Opioid therapy plays a key role in the management of chronic pain. Constipation is one of the more frequently occurring adverse effects associated with opioid therapy. Methods A retrospective cohort design study was conducted to determine the incidence of constipation in chronic pain patients who received three different long-acting opioids (transdermal fentanyl, oxycodone HCl controlled-release [CR], or morphine CR) for malignant or nonmalignant chronic pain. The data source was claims data (January 1996 through March 2001) from a 20% random sample of the California Medicaid (Medi-Cal) database. Claims data were from adult patients with chronic pain (malignant or nonmalignant) who had no prior diagnosis of constipation and no prior usage of long-acting opioids for at least 3 months before the observation period. Patients were followed for at least 3 months after the initiation of opioid therapy. ICD-9 code for diagnosis of constipation was the main outcome variable. Crude rates of constipation, annual incidence density, relative risk, and adjusted odds ratios were compared. Results A total of 1,836 patients (601 receiving transdermal fentanyl, 721 receiving oxycodone CR, and 514 receiving morphine CR) were included in the analysis. Crude (unadjusted) rates of constipation were 3.7% for transdermal fentanyl, 6.1% for oxycodone CR, and 5.1% for morphine CR (P > 0.05). Transdermal fentanyl had a lower annual incidence density and risk of constipation than oxycodone CR and morphine CR (P > 0.05). After adjusting for confounding variables, including race and supplemental opioid use, the adjusted risk of constipation was 78% greater in the oxycodone CR group (P = 0.0337) and 44% greater in the morphine CR group (P = 0.2242) than in the transdermal fentanyl group. Conclusion In this population, patients receiving transdermal fentanyl had a lower risk of developing constipation compared with those receiving oxycodone CR or morphine CR.

Mucinous cystic neoplasms of the pancreas.

Abstract: Mucinous cystic neoplasms of the pancreas (MCNP) are rare tumors with presentation and findings that differ in most cases from pancreatic pseudocysts A simple pancreatic cystic lesion in a younger-aged patient with a history of pancreatitis and endoscopic retrograde cholangiopancreatography (ERCP) demonstration of ductal communication with the cyst strongly suggests the diagnosis of a benign pseudocyst MCNP may have extensive areas without an epithelial lining, adding histologic sampling error to the potential for confusing these two entities Pancreatic pseudocysts are benign lesions treated by enteric drainage procedures, while MCNP have significant malignant potential, and resection is advised Even when clinical presentation and imaging are persuasive for a benign cyst, MCNP of the pancreas should be considered in planning, evaluation, and treatment

Alcohol Consumption: An Overview of Benefits and Risks

Abstract: Published health benefits of regular light-to-moderate alcohol consumption include lower myocardial infarction rates, reduced heart failure rates, reduced risk of ischemic stroke, lower risk for dementia, decreased risk of diabetes and reduced risk of osteoporosis. Numerous complimentary biochemical changes have been identified that explain the beneficial effects of moderate alcohol consumption. Heavy alcohol consumption, however, can negatively affect neurologic, cardiac, gastrointestinal, hematologic, immune, psychiatric and musculoskeletal organ systems. Binge drinking is a significant problem even among moderate drinkers and is associated with particularly high social and economic costs. A cautious approach should be emphasized for those individuals who drink even small amounts of alcohol. Physicians can apply the research evidence describing the known risks and benefits of alcohol consumption when counseling their patients regarding alcohol consumption.

Prevalence of occult celiac disease in patients with iron-deficiency anemia: a prospective study.

Abstract: Background: Occult celiac disease has been reported in 0 to 6% of adults presenting with iron-deficiency anemia. Most prior studies have been retrospective or screened only a selected population of patients with small bowel biopsies. To more accurately define the true prevalence of this disorder in patients presenting with iron-deficiency anemia (with or without stool hemoccult positivity), we initiated this prospective study. Methods: Esophagogastroduodenoscopy with small bowel biopsies and colonoscopy were performed in all iron-deficiency anemia patients (including those with hemoccult-positive stools) referred to the gastroenterology service during a 2-year period (1998-2000). Inclusion criteria included iron-deficiency anemia as defined by a serum ferritin <25 ng/ml and anemia with hemoglobin <12 g/dl. Patients were excluded for documented prior erosive, ulcerative, or malignant disease of the gastrointestinal tract, previous gastrointestinal surgery. overt gastrointestinal bleeding within the past 3 months, or inability to access the duodenum for biopsy. All patients underwent upper endoscopy with more than two biopsies of the distal duodenum and colonoscopy. A serum immunoglobulin A antiendomysial antibody test was to be performed in those patients with a positive small bowel biopsy to confirm the diagnosis of celiac disease. Results: One hundred five of 139 consecutive patients with iron-deficiency anemia met the inclusion criteria and were enrolled in the study. Fifty-seven men (mean age, 51.6 yr) and 48 women (mean age, 54.1 yr) constituted the study population. The demographics of this study population included 36 blacks, 38 Hispanics, and 22 whites. Nine patients were of mixed or unknown ethnic background. Forty-three and eight-tenths percent of the men and 37.5% of women had hemoccult-positive stools, accounting for a total of 40.9% of the study patients. Upper endoscopic findings included gastritis in 22.8%, gastric ulcers in 9.5%, duodenitis in 8.5%, esophagitis in 7.6%, Barrett's ulcer in 2.8%, duodenal ulcer in 2.8%, gastric polyp in 2.8%, and celiac disease in 2.8%. Colonoscopic findings included colon polyps in 21.9%, diverticula in 10.4%, and hemorrhoids in 16.1%. Multiple findings were found in 32.3% of patients, and there were no findings in 28.5% of patients. Conclusion: The prevalence of occult celiac disease in this prospective study of patients presenting with iron-deficiency anemia was 2.8%. A significant number of other gastrointestinal lesions amenable to therapy were also found on upper and lower endoscopy in these patients. Given the treatable nature of celiac disease, it should be screened for in patients with unexplained iron-deficiency anemia with or without hemoccult-positive stools.

Methodologic issues in research on religion and health.

Abstract: This study examines several methodologic issues in research on religion and health, including the measurement of the concept of religion, research designs, sampling, and statistical controls for assessing the "net" effects of religion on health outcomes. It briefly discusses differences in analytical perspectives that have contributed to the debate about the effects of religion on health. The authors review some of the methodologic problems of past research in this area of study and address what needs to be done to enhance the quality of the research. The authors conclude that the research methodology used in studies of religion and health has improved over time and that it continues to do so.

The prozone phenomenon with syphilis and HIV-1 co-infection.

Abstract: The prozone phenomenon in syphilis testing refers to a false negative response resulting from overwhelming antibody titers which interfere with the proper formation of the antigen-antibody lattice network necessary to visualize a positive flocculation test. This prozone effect in syphilis testing can be expected in cases of disproportionately high antibody titers, such as secondary syphilis, or with human immunodeficiency virus (HIV) coinfection. Clinicians need to remain familiar with the protean manifestations of syphilis to be able to exclude the prozone phenomenon.

The impact of global warming on health and mortality.

Abstract: Initial concern about the possible effects of global warming on infections has declined with the realization that the spread of tropical diseases is likely to be limited and controllable. However, the direct effects of heat already cause substantial numbers of deaths among vulnerable people in the summer. Action to prevent these deaths from rising is the most obvious medical challenge presented by a global rise in temperature. Strategies to prevent such deaths are in place to some extent, and they differ between the United States and Europe. Air conditioning has reduced them in the United States, and older technologies such as fans, shade, and buildings designed to keep cool on hot days have generally done so in Europe. Since the energy requirements of air conditioning accelerate global warming, a combination of the older methods, backed up by use of air conditioning when necessary, can provide the ideal solution. Despite the availability of these technologies, occasional record high temperatures still cause sharp rises in heat-related deaths as the climate warms. The most important single piece of advice at the time a heat wave strikes is that people having dangerous heat stress need immediate cooling, eg, by a cool bath. Such action at home can be more effective than transporting the patient to hospital. Meanwhile, it must not be forgotten that cold weather in winter causes-many more deaths than heat in summer, even in most subtropical regions, and measures to control cold-related deaths need to continue.

Patients' views about discussing spiritual issues with primary care physicians.

Abstract: Objectives The authors sought to explore patients' views about discussing spiritual issues with primary care physicians, including perceived barriers to and facilitators of discussions. Methods The study was a qualitative, semistructured interview of 10 chronically or terminally ill patients who were deliberately selected to represent a range of demographic factors (religious background, age, sex). We coded each interview and evaluated interviews for themes through content analysis. Results Themes included rationale for addressing spiritual issues; prerequisites for these discussions; roles in spiritual discussions; principles of spiritual assessment; and barriers to and facilitators of spiritual discussions. Patients justified spiritual assessment on the basis of importance of spirituality in life and health. They asserted that patients must feel honored and respected by their physician to risk discussing spiritual issues. They affirmed that physicians are helpful when legitimizing their spiritual concerns. Citing physicians' neglect of spirituality as a barrier, they affirmed that spiritual assessment in the context of other life issues facilitates spiritual discussions. Conclusions Patients' willingness to discuss spiritual issues may depend on their sense of physicians' respect for their spiritual views, attitudes about spiritual health, and qualities of openness and approachability.

Sex differences in analgesia: a randomized trial of mu versus kappa opioid agonists.

Abstract: Objectives We sought to evaluate whether there is a sex difference in the analgesic response to mu versus kappa opioids in the management of acute moderate to severe pain of injury in the emergency department. Methods The study was a randomized, double-blind, clinical trial comparing the prototypical mu-receptor agonist, morphine sulfate, to the prototypical kappa agonist, butorphanol. The primary endpoints were degree of relief by visual analog scores at 30 and 60 minutes. Statistical analysis was performed using Mann-Whitney Utest for nonparametric analysis and repeated-measures analysis of variance. Results Ninety-four patients were entered in the study, with 49 (52%) males and 45 (48%) females. Forty-six received morphine sulfate and 48 received butorphanol. There was no difference in demographics in the two groups. At 60 minutes, females had significantly lower visual analog scores with butorphanol compared with morphine (P = 0.046). At 60 minutes, there was a trend for a difference in response of males versus females to morphine, with males responding better than females (P = 0.06). Conclusion Females had better pain scores with butorphanol than morphine at 60 minutes.

A novel specific prophylaxis for menstrual-associated migraine

Abstract: Objectives Few migraine prophylactic therapies have demonstrated a 50% reduction in headaches. Even when successful, the economic burden of prophylaxis can discourage widespread usage. This article presents a pilot study of a novel, effective, specific, and inexpensive prophylactic strategy for menstrual-associated migraine. Materials and methods Eleven women with menstrual-associated migraine and fewer than 14 days of headache per month were identified from prospective enrollment at a gynecology practice and retrospective chart review at a headache center. Exclusion criteria included current use of prophylactic therapy for migraine. Methods Patients received open-label therapy with an oral contraceptive containing 20 microg ethinyl estradiol on days 1 to 21, supplemented with 0.9 mg conjugated equine estrogens on days 22 to 28. Headache intensity and bleeding were recorded in diaries that plotted headache days by oral contraceptive pill days. Results All of the patients achieved at least a 50% reduction in number of headache days per cycle (mean 77.9% reduction); 10 of the 11 women achieved at least a 50% reduction in weighted headache score (mean 76.3% reduction). Conclusions All currently available estrogen-containing oral contraceptives produce a premenstrual fall in ethinyl estradiol concentration equal to or greater than 20 microg. Estrogen supplementation during the placebo week can reduce the magnitude of this fall to less than 20 microg. When the decline is limited to the equivalent of 10 microg ethinyl estradiol, menstrual-associated migraine is prevented. At an average cost of six dollars per headache-day prevented, this represents an effective and inexpensive strategy for a common migraine trigger.

Handgrip strength, pulmonary function tests, and pulmonary muscle strength in fibromyalgia syndrome: is there any relationship?

Abstract: Objective: It has been reported that patients with fibromyalgia syndrome (FMS) have lower maximal respiratory pressures than healthy subjects, indicating reduced pulmonary muscle strength. It has also been reported that patients with FMS have reduced grip strength. In this study, we aimed to examine the possible relationship between handgrip strength as a determinant of peripheral muscle strength and pulmonary muscle strength in patients with FMS by comparing them with healthy controls. Methods: Forty-one consecutive women with FMS (diagnosed according to the American College of Rheumatology 1990 criteria) were compared with 40 age- and body mass index-matched healthy female controls. Pulmonary function tests were assessed by spirometry. Maximal pulmonary pressures were evaluated using an oral pressure meter. A dyspnea score was obtained. Pain was scored according to visual analogue scale and chest pain was classified (0-9) in fibromyalgia patients. Chest expansion was also measured in the two groups. Tender points were also evaluated in FMS patients. Grip strength (Jamar handheld dynamometer) was also measured in the two groups. Results: The difference in pulmonary function tests was not statistically significant between groups. Maximal respiratory pressures (maximum inspiratory pressure and maximum expiratory pressure) and endurance (maximum ventilatory volume) were significantly lower in patients with FMS than in controls. There was also a statistically significant difference between groups regarding grip strength. There was also significant correlation between maximal inspiratory pressure and maximal expiratory pressure values and handgrip strength in patients with FMS. Conclusion: These data indicate that handgrip strength may be a determinant of pulmonary muscle strength in fibromyalgia patients.

A review of postpartum depression for the primary care physician.

Abstract: Postpartum depression (PPD) occurs more commonly in US women than most physicians realize PPD is present in at least 10% and up to 20% of women in the United States within the first 6 months of delivery The rate may be 25% or higher in women with a history of postpartum depression after a previous delivery Over half of all women who develop postpartum depression still suffer symptoms a year later This condition causes tremendous morbidity in terms of suffering and decreased quality of life As with other psychiatric disorders, patients with PPD are more likely to seek help from their primary care doctors than from mental health professionals Therefore, these providers should be equipped with the knowledge and tools necessary to properly care for women with PPD

Burnout in residency: a statewide study.

Abstract: OBJECTIVE: To determine the prevalence of burnout in residents in obstetrics and gynecology through the use of a validated tool. METHODS: The Maslach Burnout Inventory Human Services questionnaire is a previously validated tool that measures burnout. Obstetrics and gynecology residents from Texas were invited to participate in this study in 2002. The Maslach Burnout Inventory Human Services questionnaire and a demographic survey were distributed to each resident. Responses were anonymous and returned by mail. Contingency coefficient and chi2 tests were used for analysis; values of P < 0.05 were significant. RESULTS: Residents (n = 368) from 17 programs in Texas were surveyed. Responses were received from 14 programs (82.4%), with 136 surveys (37%) returned. Overall, 38.2% reported high emotional exhaustion, 47.1% reported high depersonalization, and 19.1% reported reduced personal accomplishment. The number of residents experiencing true burnout (high emotional exhaustion, high depersonalization, and low personal accomplishment) was 17.6% (n = 24). CONCLUSIONS: High levels of emotional exhaustion and depersonalization occur in some residents. Burnout in residents included in this study was approximately 18%.

Religion, aging, and health: exploring new frontiers in medical care.

Abstract: The purpose of this review article is to selectively examine research that was designed to evaluate the relation between religious involvement and health among older people Four facets of religion are examined in detail: church-based social support, religious coping, forgiveness, and prayer In addition, potential negative effects of religion on health are discussed Negative interaction in the church as well as religious doubt are evaluated in this respect Throughout, an effort is made to show how current research on religion and health may be used to provide more comprehensive care for our aging population

Emergency department volume and acuity as factors in patients leaving without treatment.

Abstract: Objectives:Patients who leave emergency departments (EDs) without treatment represent potential personal and hospital liability. Many department-dependent factors have been linked to patients who leave without treatment (LWT) in high-volume EDs. The authors studied how department volume and acuity i

Methimazole-induced cholestatic jaundice.

Abstract: Methimazole is a widely used and generally well-tolerated antithyroid agent. A 43-year-old woman had severe jaundice and itching 1 month after receiving methimazole (10 mg tid) and propranolol (20 mg tid) for treatment of hyperthyroidism. The patient continued treatment for another 4 days after the appearance of jaundice until she finished both medications. When seen at the emergency department 2 weeks later, she still had severe icterus, pruritus, and hyperbilirubinemia, formed mainly of the conjugated fraction. Methimazole-induced cholestasis was diagnosed, and propranolol therapy was resumed. Over the following 9 days, the symptoms improved and plasma bilirubin levels were normal after 12 weeks without methimazole. In rare cases within the first few weeks of therapy, this drug can cause severe and reversible cholestatic jaundice. Physicians and patients should be aware of this adverse effect so that, upon occurrence, they can discontinue methimazole therapy and avoid unnecessary invasive procedures.

Thoracic packing for uncontrolled bleeding in penetrating thoracic injuries.

Abstract: We present a series of three patients who suffered penetrating thoracic injury, and in whom thoracic packing was used as a life-saving procedure. Survival among these patients paralleled the severity and extent of the original injuries. Restriction of cardiac filling and lung expansion are potential deterrents from using this technique; however, its use seems to be a valid adjunct, especially in the setting of chest wall bleeding coming from the intercostal arteries. Damage control surgery in pentrating thoracic trauma, including thoracic packing, is a sound alternative when uncontrollable bleeding, hypothermia and coagulopathy compromises the survival of a patient.

Metastatic spine tumors.

Abstract: Cancer is the second leading cause of death in the United States, and vertebral body metastases often occur in systemic malignancy. Metastatic spinal tumors may present with pain or neurologic deficit, or may be detected during screening examinations in patients with known malignancy. Management of spinal metastases remains controversial. The role of surgery, especially decompressive laminectomy without stabilization, has been questioned. Recent series attest to the beneficial role of surgery, emphasizing anterior and combined decompression and stabilization procedures. We review the relevant literature on metastatic spinal tumors, assessing imaging strategies, adjuvant treatment, patient selection, and results and complications. Operative decompression and stabilization is an important tool in the management of spinal metastatic disease. Patient selection and appropriate use of anterior and/or posterior decompression and stabilization are necessary to optimize surgical results.