Showing papers in "Southern Medical Journal in 2007"

Noise Pollution: A Modern Plague

Abstract: Noise is defined as unwanted sound. Environmental noise consists of all the unwanted sounds in our communities except that which originates in the workplace. Environmental noise pollution, a form of air pollution, is a threat to health and well-being. It is more severe and widespread than ever before, and it will continue to increase in magnitude and severity because of population growth, urbanization, and the associated growth in the use of increasingly powerful, varied, and highly mobile sources of noise. It will also continue to grow because of sustained growth in highway, rail, and air traffic, which remain major sources of environmental noise. The potential health effects of noise pollution are numerous, pervasive, persistent, and medically and socially significant. Noise produces direct and cumulative adverse effects that impair health and that degrade residential, social, working, and learning environments with corresponding real (economic) and intangible (well-being) losses. It interferes with sleep, concentration, communication, and recreation. The aim of enlightened governmental controls should be to protect citizens from the adverse effects of airborne pollution, including those produced by noise. People have the right to choose the nature of their acoustical environment; it should not be imposed by others.

Splenosis: a review.

Abstract: Splenosis is a common benign condition that occurs after splenic rupture via trauma or surgery. Splenosis is usually found incidentally and unless symptomatic, therapy is not indicated. However, since radiographically it can mimic malignancy, most patients have an extensive workup. The diagnostic method of choice is nuclear scintigraphy, specifically, a heat-damaged red blood cell scan. Splenosis usually occurs within the abdominal and pelvic cavities, but patients have been described with intrathoracic, subcutaneous, intrahepatic and intracranial lesions.

Correlation between high risk obesity groups and low socioeconomic status in school children.

Abstract: OBJECTIVE Obesity is a major health problem among children and adolescents which is potentially affected by socioeconomic status (SES). The high risk group (HRG) comprises those youths with a body mass index (BMI) between the 85th and 95th percentile (at risk for overweight) and > or = 95th percentile (overweight). We sought a potential link between the HRG and SES. METHODS Public schools in Chesterfield County, Virginia measured BMI among students in kindergarten and third, seventh, and tenth grades. We assessed SES based on eligibility for the National School Lunch Program and the percentage of the school-age population living in poverty based on per capita income from the 2000 Census. RESULTS From 28 to 38% of children and adolescents were in the high risk group. Low SES had robust and highly significant correlations with HRG status with r-values ranging from 0.565 to 0.842, P < 0.0001. CONCLUSIONS Low SES appears to be an important factor in childhood and adolescent obesity.

A descriptive analysis of authorship within medical journals, 1995-2005.

Abstract: INTRODUCTION The emphasis on publications for promotion in academic medicine would lead one to the theory that authorship numbers would increase proportionally with this emphasis. To investigate authorship trends across a number of periodicals, we performed a descriptive study comparing two full years of published articles spaced ten years apart from five medical journals. METHODS Physician reviewers each reviewed all articles of one medical journal for the 1995 and 2005 publication years. Reviewed journals included Academic Emergency Medicine (AEM), Annals of Emergency Medicine (AnnEM), Annals of Internal Medicine (AIM), Journal of Trauma (JT), and New England Journal of Medicine (NEJM). Data collected for each article were number of authors, ordinal number of the corresponding author, type of study described, whether the described study was a multicenter trial, whether authorship listed included a "study group," and whether any author was also an editor of the journal. RESULTS A total of 2927 articles were published in the five journals in 1995, and of these, 1401 (47.9%) were analyzed after the exclusion criteria had been applied; for 2005 a total of 3630 articles were published and of these, 1351 (37.2%) were included in the analysis. Across all five journals the mean number of authors per article increased from 4.66 to 5.73 between 1995 and 2005 (P < 0.0001), and four of the five journals individually had statistically significant increases in the number of authors per article. More articles had a journal editor as an author in 2005 (increased from 7.8% to 11.0%, P = 0.004), though no single journal had a statistically significant increase. CONCLUSION We describe a trend of increasing mean authors, editorial authorship, study groups, and multicenter trials over time with fewer solo authors now publishing original research or case reports. The academic medical community must pursue an authorship requirement consensus to assure that a standard of contribution for all authors on a given paper is met.

Henoch-Schönlein purpura: a review article.

Abstract: Henoch-Schonlein purpura (HSP) is the most common vasculitis of childhood. Although HSP is typically a disease of children, adult cases have been described. HSP can affect multiple organs with a characteristic rash present in all patients. Most cases resolve with symptomatic treatment, but serious complications can occur such as renal failure. Primary care physicians should be well aware of the disease because the true incidence is probably underestimated.

Minorities, the poor, and survivors of abuse: HIV-infected patients in the US deep South.

Abstract: BACKGROUND: The HIV/AIDS epidemic in the U.S. South is undergoing a marked shift toward a greater proportion of new HIV/AIDS cases in women, African-Americans, and through heterosexual transmission. METHODS: Using consecutive sampling, 611 participants were interviewed from eight Infectious Diseases clinics in five southeastern states in 2001 to 2002. RESULTS: Sixty four percent of participants were African-American, 31% were female, and 43% acquired HIV through heterosexual sex; 25% had private health insurance. Eighty-one percent were on antiretroviral therapy, and 46% had HIV RNA viral loads (VL) Language: en

Early and late arrhythmogenic effects of doxorubicin.

Abstract: Background To determine the incidence of early and late arrhythmogenic effects of doxorubicin-containing chemotherapy regimens. Patients and methods A prospective study including 29 patients who were treated with doxorubicin-containing regimens. Cardiac evaluation was based on 24-hour electrocardiographic monitorization (Holter), which was performed during the first cycle of doxorubicin-containing regimens, as well as after the last cycle of chemotherapy. Results The mean age of the patients was 45.8 +/- 15.1 (range 18-69). Holter records obtained during the first cycle of treatment revealed varying arrhythmias in 19 patients (65.5%) and in 18 (62.1%) patients after completion of therapy. One patient presented with syncope and both Mobitz Type 2 atrioventricular block and complete atrioventricular block were demonstrated. The patient subsequently underwent permanent pacemaker implantation. Conclusions Doxorubicin may result in arrhythmias both in early and late periods of treatment. These arrhythmias are rarely life threatening.

Patient Complaints and Malpractice Risk in a Regional Healthcare Center

Abstract: Objective To study the association between physicians' complaint records and their risk management experiences in a regional healthcare center. Data sources Patient complaints about physicians in a large border state medical center's hospital and outpatient clinics were recorded and coded. The study period was from January 2001 through December 2003. These records were linked to the counterpart physicians' data covered by the institutions' risk management plan through June 2004. Study design and data collection All physicians at the institution who had contact with patients during the study period were identified as surgeons or non-surgeons. Complaints for these physicians were recorded by the institution's Office of Patient Relations (OPR) and independently coded using a standardized protocol to characterize the nature of the problem and to uniquely identify the person complained about. The complaint records were then linked to the risk management files (RMFs) for the defined physician cohort. In addition, these data were supplemented with clinical service values (RVUs) which were available for 338 members (76%) of the 445 member cohort. Principal findings Both patient complaints and risk management events were higher for surgeons than for non-surgeons. This was true for the number of RMFs, those involving expenditures, and for lawsuits. Logistic regression was used to assess the effects of complaint counts, practice type and volume of clinical activity. All were statistically significant in predicting the number of RMF openings, RMF openings with expenditures and lawsuits. Predictive concordance was 75% or greater for each of the three risk management outcomes. Conclusions Expressions of patient dissatisfaction and practice type are significantly related to risk management experiences in a regional medical center. Associations of risk management experiences with volume of clinical activity (RVUs) for surgeons in the regional medical center environment were not as strong as those found in a similar study reported from an academic medical center.

Spirituality and depression: a look at the evidence.

Abstract: Depression is one of the strongest predictors of suicide, especially when accompanied by hopelessness. People often commit suicide when they perceive that there is no way out of an intolerably painful situation, or when they see no purpose or meaning to a life of seemingly unending suffering. Depressive illness can itself make people feel this way, and depression is very common among patients for whom medical clinicians care. Studies of medical inpatients have reported rates of depression approximating 50%. When patients are asked how they are able to manage with the stress of medical illness, disability, and pain, they frequently report that religious beliefs and practices are a source of comfort and strength. Religious beliefs can be a source of hope for those facing difficult life problems, especially medical illness, and it is not surprising that religious activity is positively related to hope and optimism and negatively related to depression. I review here some of the research that has demonstrated a relationship between religion/spirituality and depression in patients with physical illness. When medical patients are asked what they are doing that enables them to cope, in some areas of the country nearly 90% of hospitalized patients report that religion is a helpful resource, and 40% indicate that religion is the most important factor that keeps them going. In a study of unconventional therapies for pain among a random sample of 382 persons with musculoskeletal complaints in San Diego, California, the most commonly mentioned therapy was prayer, which was also rated the second most helpful of 19 therapies examined. Likewise, in a study of 100 patients on the day before cardiac surgery at the University of Alabama Medical Center in Birmingham, 95% reported using prayer and 70% rated prayer as “extremely helpful” for coping with surgery (ie, gave prayer a score of 15 on a 0–15 helpfulness scale). Thus, according to patients themselves, religious practices facilitate adaptation to illness. However, just because patients report that religion is helpful does not mean that such is actually the case. Many persons in the United States may report that they use religion to cope because this is the more socially acceptable way of responding to such questions, regardless of whether it is actually true for them. Nevertheless, when the religiousness of patients is measured, studies usually indicate that those who are more religious experience less depression (ie, are coping better). For example, in a study of 30 women over age 65 with hip fracture in the Chicago area, degree of religious involvement was associated with less depression (Geriatric Depression Scale) and longer walking distances at discharge. These relationships persisted after controlling for severity of medical illness. Likewise, a study of 850 hospitalized men found that the degree to which patients used religion to cope was significantly and inversely related to depressive symptoms (whether measured by the self-rated Geriatric Depression Scale or by the clinician-rated observer-rated Hamilton Depression Rating Scale). In that study, religious coping during hospitalization also predicted fewer depressive symptoms several months later in a subgroup of 201 readmitted patients, controlling for multiple other predictors of depression. Religious coping was the strongest predictor of future depressive symptoms among 14 other baseline predictors (accounting for 45% of the explained variance in depression). However, religious coping was only associated with certain types of depressive symptoms. Loss of interest, feeling of worthlessness, withdrawal from social interactions, loss of hope, and other “cognitive” symptoms of depression were significantly less common among those using religion to cope, whereas “somatic” symptoms such as weight loss, insomnia, loss of energy, and decreased concentration were unrelated to religious coping. This suggests that once depression worsens to the point that somatic symptoms are present, then religious involvement may be less effective in resolving symptoms (and may itself be influenced by the depression). In another prospective study, 87 male and female depressed medical inpatients (diagnosed with major or minor depression using the Diagnostic Interview Schedule) were identified and followed up for an average of 47 weeks after discharge. Baseline patient characteristics during hospitalization were examined as predictors of speed of depression remission. Patients who were more deeply religious (ie, greater intrinsic religiosity) remitted from depression 70% From the Departments of Psychiatry and Behavioral Sciences and Medicine, Duke University Medical Center, GRECC VA Medical Center, Durham, NC.

Beneficial effects of periodontal treatment on metabolic control of hypercholesterolemia

Abstract: Background The authors aimed to evaluate whether local periodontal therapy may influence plasma lipid levels in patients with periodontitis. Methods Fifty patients (31 females and 19 males, age 36-66 yr) were randomly assigned to the treatment and control groups. Lipid profile and dental variables were measured at baseline and at the end of the study in both groups. Results In the third month, there was a significant decrease in total and low density lipoprotein (LDL) cholesterol levels of the treatment group compared with baseline values. Also, the reduction in bleeding on probing, pocket depth, attachment loss, plaque index and gingival index were statistically significant in the treatment group. Conclusions The present study indicates that periodontitis causes changes in total and LDL cholesterol levels and local periodontal treatment resulted in a significant decrease in these markers. These results suggest a potential effect of periodontitis-driven systemic inflammation on lipid metabolism.

The impact of bronchiectasis in clinical presentation of asthma.

Abstract: Background Though asthma and bronchiectasis are two different diseases, their coexistence has been shown in many patients. The aim of this study was to evaluate the clinical features of asthmatics with bronchiectasis compared with pure asthmatics. Methods We evaluated 1680 asthmatics followed-up in our clinic. Fifty-one asthmatics had the diagnosis of bronchiectasis. These patients were compared with fifty-one age and gender matched asthmatics without bronchiectasis. Results The prevalence of bronchiectasis among the asthmatics was 3%. Asthma diagnosis was made at the age of 33.2 +/- 16.8 years for asthmatics with bronchiectasis and 39.5 +/- 16.2 years for pure asthmatics (P = 0.05). Asthmatics with bronchiectasis mostly had severe persistent asthma (49.0%), while pure asthmatics mostly had mild persistent and intermittent asthma (69.4%). History of hospitalization due to severe asthma exacerbation and presence of chronic respiratory failure was significantly higher in bronchiectatic group. Conclusions These data show that bronchiectasis can contribute to severe and difficult to control asthma with pulmonary complications like chronic respiratory failure.

Electroconvulsive therapy: a review of history, patient selection, technique, and medication management.

Abstract: Electroconvulsive therapy (ECT) is a safe and effective treatment for severe and persistent depression, bipolar disorder and schizophrenia. Though ECT is now over 60 years old, it remains an underutilized treatment today. History, patient selection, safety, and characteristics of the treatment stimulus, technique, and medications used in ECT are reviewed. Dosing strategies, as pertaining to seizure threshold, will be considered. Mechanisms of action, especially with regard to serotonin, norepinephrine, and dopamine receptor expression will be discussed.

Management of chronic noncancer pain in the primary care setting.

Abstract: While opioids are regarded as the mainstay of chronic pain management, their use is controversial in the minds of many primary care physicians due to clinical concerns about dependence, abuse, and addiction and medicolegal concerns regarding state and federal regulatory authorities. For patients with moderate to moderately severe pain, the treatment of choice is a long-acting opioid or opioid combination drug product to provide sustained analgesia along with improvements in sleep quality, compliance, and possibly quality of life. Careful screening of patients being considered for long-term opioid therapy with validated questionnaires can identify patients who may have difficulties in managing opioids. These patients should not be denied access to opioid therapy, but they do require focused monitoring and case management. Ongoing monitoring should focus on the 4 A's (ie, analgesia, activities of daily living, adverse effects, and aberrant drug-related behaviors), and all aspects of patient care must be thoroughly documented.

Alcohol use and religiousness/spirituality among adolescents.

Abstract: BACKGROUND: Previous studies indicate that religiousness is associated with lower levels of substance use among adolescents, but less is known about the relationship between spirituality and substance use. The objective of this study was to determine the association between adolescents' use of alcohol and specific aspects of religiousness and spirituality. METHODS: Twelve- to 18-year-old patients coming for routine medical care at three primary care sites completed a modified Brief Multidimensional Measure of Religiousness/Spirituality; the Spiritual Connectedness Scale; and a past-90-days alcohol use Timeline Followback calendar. We used multiple logistic regression analysis to assess the association between each religiousness/spirituality measure and odds of any past-90-days alcohol use, controlling for age, gender, race/ethnicity, and clinic site. Timeline Followback data were dichotomized to indicate any past-90-days alcohol use and religiousness/spirituality scale scores were z-transformed for analysis. RESULTS: Participants (n = 305) were 67% female, 74% Hispanic or black, and 45% from two-parent families. Mean +/- SD age was 16.0 +/- 1.8 years. Approximately 1/3 (34%) reported past-90-day alcohol use. After controlling for demographics and clinic site, Religiousness/Spirituality scales that were not significantly associated with alcohol use included: Commitment (OR = 0.81, 95% CI 0.36, 1.79), Organizational Religiousness (OR = 0.83, 95% CI 0.64, 1.07), Private Religious Practices (OR = 0.94, 95% CI 0.80, 1.10), and Religious and Spiritual Coping--Negative (OR = 1.07, 95% CI 0.91, 1.23). All of these are measures of religiousness, except for Religious and Spiritual Coping--Negative. Scales that were significantly and negatively associated with alcohol use included: Forgiveness (OR = 0.55, 95% CI 0.42-0.73), Religious and Spiritual Coping--Positive (OR = 0.67, 95% CI 0.51-0.84), Daily Spiritual Experiences (OR = 0.67, 95% CI 0.54-0.84), and Belief (OR = 0.76, 95% CI 0.68-0.83), which are all measures of spirituality. In a multivariable model that included all significant measures, however, only Forgiveness remained as a significant negative correlate of alcohol use (OR = 0.56, 95% CI 0.41, 0.74). CONCLUSIONS: Forgiveness is associated with a lowered risk of drinking during adolescence. Language: en

Addressing cultural barriers to the successful use of insulin in Hispanics with type 2 diabetes.

Abstract: Hispanics experience a higher rate of diabetes than non-Hispanic whites and tend to have worse glycemic control and a greater risk of diabetes-related complications. Once oral antidiabetic agents become insufficient, insulin plays an important role in achieving glycemic goals. However, many Hispanic patients are resistant to initiating insulin therapy or hesitant to increase doses, as necessary, to control their glucose levels. Barriers to insulin therapy include socioeconomic issues (eg, cost, insurance status), language difficulties, poor health literacy, and cultural beliefs that impact the patient-provider relationship and negatively affect patients' perceptions of diabetes and insulin. Healthcare providers can help overcome these issues and improve patient-provider communication by practicing culturally competent care. Implementation of a simple titration regimen using once-daily basal insulin may enable Hispanic patients to maintain glycemic control and improve outcomes.

Blastomycosis of bones and joints.

Abstract: A retrospective study of 45 patients hospitalized with blastomycosis of bones or joints revealed 41 cases of osteomyelitis and 12 cases of septic arthritis. The majority were men (35 [78%] patients) and non-Aboriginal (32 [71%] patients). Median time from the onset of symptoms to hospitalization was shorter in women than men (male, 48 d; female, 14 d; P < 0.02), and shorter for Aboriginals than non-Aboriginals (non-Aboriginal, 50 d; Aboriginal, 19 d; P < 0.04). Cutaneous disease was present in 33 (73%) patients, and lung involvement was present in 29 (64%) patients. The most common osseous sites of involvement were the lower limb and axial skeleton. Common orthopaedic symptoms of bone lesions included bone pain in 42 (78%) patients, swelling in 32 (59%) patients, and soft tissue abscesses in 21 (39%) patients. Joint infection (12 patients) manifested as a monoarticular arthropathy presenting with effusion in 9 (75%) patients, pain in 8 (67%) patients, and decreased range of motion in 5 (42%) patients. Osseous blastomycosis can mimic bacterial infection and should be included in the differential diagnosis of bone and joint infection in patients who have visited or who live in geographic regions where B dermatitidis is endemic.

Spirituality and alcoholics anonymous.

Abstract: What can be confidently said about AA in general and about the role of spirituality in AA in particular? First, there is convincing evidence that alcoholism severity predicts later AA attendance. Second, atheists are less likely to attend AA, relative to individuals who already hold spiritual and/or religious beliefs. However, belief in God before AA attendance does not offer any advantage in AA-related benefits, and atheists, once involved, are at no apparent disadvantage in deriving AA-related benefits. Third, the spiritually-based principles of AA appear to be endorsed in AA meetings regardless of the perceived social dynamics or climate of a particular meeting, eg, highly cohesive or aggressive. Fourth, significant increases in spiritual and religious beliefs and practices seem to occur among AA-exposed individuals. Fifth, in spite of much discussion to the contrary there is little evidence that spirituality directly accounts for later abstinence. We are finding, however, that spirituality has an important indirect effect in predicting later drinking reductions. Specifically, in the past 20 years a number of effective methods have been developed to facilitate initial AA attendance (AA dropout is high, with some estimates ranging as high as 80%). Interventions that lead to initial increases in spirituality appear to lead to sustained AA affiliation, which, in turn, produces sustained recovery over time.

Chronic eosinophilic pneumonia: a review

Abstract: Chronic eosinophilic pneumonia (CEP) is a disease of unknown cause. The hallmark of CEP is eosinophil accumulation in the lungs. While the triggering factor is unknown, eosinophil accumulation in the lungs is now believed to be secondary to the actions of eosinophil-specific chemoattractants, including eotaxin and regulated upon activation, normal T-cell expressed and secreted (RANTES), and IL-5 released from Th2 lymphocytes in the lungs. There is a female preponderance in CEP, with a peak incidence in the 5th decade; the onset is insidious with weight loss, cough, and dyspnea. An atopic history is common, but asthma is not a prerequisite for the development of CEP. Airways obstruction may develop during the course of CEP, but may also result from CEP. The chest x-ray usually shows bilateral peripheral shadows, which may be migratory. Peripheral eosinophilia is usual. Standard treatment of CEP is with oral steroids, usually with dramatic resolution of symptoms and radiographic changes; however, relapses are common when the daily steroid dose is reduced below 15 mg. Current data suggest that when treatment is stopped, relapse is common in the majority of patients (>80%) followed for a sufficiently long period of time. Some recent reports suggest that treatment with inhaled steroids may be of some value in this condition.

A comparison of polyethylene glycol laxative and placebo for relief of constipation from constipating medications.

Abstract: OBJECTIVES Medications often cause constipation and little data are available concerning treatment interventions. This study was designed to evaluate the safety and efficacy of polyethylene glycol (PEG) 3350 laxative (MiraLax) for relief of constipation from medicines associated with symptoms of constipation. METHODS Study subjects were enrolled who met defined criteria for chronic constipation and were also taking medications that were associated with a reported side effect incidence of more than 3% constipation. Subjects were randomized into a double-blind, parallel, multicenter study where they received 17 g per day of PEG laxative or placebo for 28 days. The primary efficacy variable, "Treatment Success," was defined as relief of ROME II criteria for constipation over the last 7 days of the treatment period. Various secondary measures were also assessed. Daily bowel movement experience, patient perception of efficacy, and safety information were recorded in a diary. Laboratory testing was performed at baseline and at end of study for hematology and blood chemistry, including BUN, calcium, electrolytes, and TSH. RESULTS One hundred patients were enrolled at 4 study centers. Successful treatment according to the primary efficacy variable was seen in 78.3% of PEG and 39.1% of placebo subjects (P < 0.001). Similar results were observed in a subgroup of 28 elderly subjects. Secondary measures of number of bowel movements, complete bowel movements, satisfactory bowel movements, straining at stool and stool consistency also showed statistically significant results in favor of PEG compared with placebo (P < or = 0.01) after the first week of treatment. There were no differences inpatient reported scores for gas, cramping, or bloating between PEG and placebo. No significant differences in laboratory findings or adverse events, including the gastrointestinal category, were observed. Diarrhea and flatulence occurred more frequently with PEG treatment, although they were not individually statistically different from placebo. Similar results were observed when these symptoms were analyzed for differences due to gender, race, or age. CONCLUSIONS PEG laxative is safe and effective for use in treating constipation in patients taking constipating medications.

Additional evidence of the abuse potential of quetiapine.

Abstract: Quetiapine is an atypical antipsychotic agent approved by the FDA for the treatment of schizophrenia, acute mania, and bipolar depression. Recently, reports of medication abuse, particularly intranasal and i.v. abuse, have been described. Three cases of oral misuse of quetiapine are presented and clinical implications are discussed. Clinicians should exercise caution when prescribing quetiapine to patients at risk for substance abuse.

Recognizing and managing severe sepsis: a common and deadly threat.

Abstract: Through a literature review, the epidemiology and pathophysiology, including alterations in inflammation, coagulation, and impaired fibrinolysis that occur in the course of severe sepsis, is presented. Treatment guidelines that are evidence-based and endorsed by 11 professional societies representing multispecialty groups are described. Severe sepsis is common; 750,000 cases are estimated to occur annually in the United States. The mortality rate for severe sepsis still ranges from 30 to 50%, and is as high as 80 to 90% for septic shock and multiple organ dysfunction. Severe sepsis exists along a continuum initiated by a localized infection that triggers a systemic response. A cascade of inflammation and activation of the coagulation system associated with impaired fibrinolysis leads to alterations in microvascular circulation associated with organ dysfunction, severe sepsis, multiple organ dysfunction syndrome, and death. In an attempt to improve care and reduce mortality, the Surviving Sepsis Campaign and The Institute for Healthcare Improvement (IHI) have created two sepsis treatment bundles.

Immediate impact of smoke-free laws on indoor air quality.

Abstract: Smoke-free laws significantly impact indoor air quality. However, the temporal effects of these laws on indoor air pollution have not been determined. This paper assesses the temporal impact of one smoke-free law on indoor air quality. This quasi-experimental study compared the indoor air quality of nine hospitality venues and one bingo hall in Georgetown, Kentucky, before and after implementation of a 100% smoke-free workplace law. We made real-time measurements of particulate matter with 2.5 microm aerodynamic diameter or smaller (PM2.5). Among the nine Georgetown hospitality venues, the average indoor PM2.5 concentration was 84 microg/m3 before the law took effect. The average indoor PM2.5 concentrations in nine compliant venues significantly decreased to 18 microg/m3 one week after the law took effect. Three venues having 82 microg/m3 before the law had significantly lower levels from the first day the law was implemented, and the low level was maintained. Compliance with the law is critical to achieving clean indoor air. Indoor air pollution in the bingo hall was not reduced until the establishment decided to comply with the law. The smoke-free law showed immediate impact on indoor air quality.

Spirituality in the recovery from persistent mental disorders.

Abstract: Mental health systems in this country are undergoing a quiet revolution. Former patients and other advocates are working with mental health providers and government agencies to incorporate spirituality into mental healthcare. While the significance of spirituality in substance abuse treatment has been acknowledged for many years due to widespread recognition of the therapeutic value of 12-step programs, this is a new development in the treatment of serious mental disorders such as bipolar disorder and schizophrenia. The incorporation of spirituality into treatment is part of the recovery model which has become widely accepted in the US and around the world. In 1999, the Surgeon General, in a landmark report on mental health, urged that all mental health systems adopt the recovery model. 1 What distinguishes the recovery model from prior approaches in the mental health field is the perspective that people can fully recover from even the most severe forms of mental disorders. Services and research are being reoriented toward recovery from severe or long-term mental illnesses. 2 This creates an orientation of hope rather than the “kiss of death” that diagnoses like schizophrenia once held. One hundred years ago, Emil Kraepelin identified the disorder now known as schizophrenia as dementia praecox, a chronic, unremitting, gradually deteriorating condition, having a progressive downhill course with an end state of dementia and incompetence. 3 However, researchers have established that people diagnosed with schizophrenia and other serious mental disorders are capable of regaining significant roles in society and of running their own lives. There is strong evidence that most persons, even with long-term and disabling forms of schizophrenia, do “recover,” that is, enjoy lengthy periods of time free of psychotic symptoms and partake of community life as independent citizens. 4 Daniel Fisher, a former patient, now a psychiatrist and internationally renowned advocate for the recovery model, maintains that “Believing you can recover is vital to recovery from mental illness. Recovery involves self-assessment and personal growth from a prior baseline, regardless of where that baseline was. Growth may take the overt form of skill development and resocialization, but it is essentially a spiritual revaluing of oneself, a gradually developed respect for one’s own worth as a human being. Often when people are healing from an episode of mental disorder, their hopeful beliefs about the future are intertwined with their spiritual lives, including praying, reading sacred texts, attending devotional services, and following a spiritual practice.” 5

Spirituality and addiction.

Abstract: A Mysterious Overlap Drug use and spirituality have a curiously intertwined history. Some world religions eschew or prohibit the use of certain drugs, for example, the banning of alcohol within Islam and Mormonism. The ancient aphorism spiritus contra spiritum implies a mutual incompatibility of alcohol and spirituality: each drives out the other. Substance dependence is, by diagnostic definition, a process whereby the drug progressively displaces previous priorities, relationships and values, and becomes the central concern of a person’s life—a modern analogue of idolatry. On the other hand, across diverse cultures, various substances have been used specifically as vehicles in the search for the sacred, among them lysergic acid derivatives, Psilocybe and several other genera of mushrooms, mescaline-containing cacti such as peyote, nightshade species such as Jimsonweed, and many others. Psychoactive drugs also occupy a place of honor in sacraments and rituals of some world religions, for example, wine in Judaism and Christianity and tobacco in Native American religion. It is as though, from a religious perspective, there is something significant about “spirits” and other psychoactive drugs. Avram Goldstein, whose classic work led to the understanding of endogenous opioids, also studied “thrills in music,” the common experience of awe and chills occurring at predictable moments in classical music. In a double-blind trial, he found that naloxone reliably suppressed these experiences, suggesting that they are mediated by endorphins. Furthermore, spirituality has long been regarded as having central importance in the treatment of and recovery from addiction. Alcoholics Anonymous (AA) and related worldwide mutual-help programs conceptualize recovery through the “12 Steps” that are unambiguously spiritual in focus, emphasizing reliance on a Higher Power and the practice of prayer and meditation as means for promoting spiritual awakening and “conscious contact with God.”

Overlapping features of thrombotic thrombocytopenic purpura and systemic lupus erythematosus.

Abstract: Although thrombotic thrombocytopenic purpura (TTP) and systemic lupus erythematosus (SLE) are distinct entities, they may appear as overlapping clinical syndromes from multiple perspectives: pathogenesis, patient demographics, clinical features, and management (Table). Our interest in the similarities of these two syndromes began with our experience that patients may be diagnosed with TTP following an established SLE diagnosis and also that patients may develop SLE following recovery from an episode of TTP. To extend our observations, we systematically reviewed all published reports describing patients who had been diagnosed with both TTP and SLE and identified 87 patients. Although one of the disorders, TTP or SLE, may merely mimic the other, in some patients, there is serologic as well as clinical evidence to support the diagnosis of both TTP and SLE. For our comparison of these two syndromes in this review, we have restricted our discussion of TTP to the subset of patients who have an acquired severe deficiency of ADAMTS13 (A disintegrin and metalloprotease with thrombospondin-1-like repeats), a von Willebrand factor (VWF)-cleaving protease. The acquired severe ADAMTS13 deficiency is typically described as less than 5% activity, caused by an autoantibody that inhibits protease function. Although patients with severe ADAMTS13 deficiency are a minority of all patients who are clinically diagnosed with TTP, they have the most clearly documented diagnosis, as well as an established autoimmune etiology. Similarly, we have restricted our discussion of SLE to patients who fulfill current classification, meeting as least 4 of 11 American College of Rheumatology (ACR) SLE criteria. Incidence The incidence of these syndromes is similar (Table). The incidence in the region of the Oklahoma TTP-HUS Registry for all patients who are clinically diagnosed with TTP is 11.3 per 10 population per year, but the incidence of patients with acquired severe ADAMTS13 deficiency is only 1.7 per 10 population per year. The incidence of SLE is 2.4 per 10 population per year. The six-fold difference between the incidence for all patients who are clinically diagnosed with TTP and the incidence for patients with acquired severe ADAMTS13 deficiency emphasizes the broad clinical spectrum of patients who are initially diagnosed with TTP. Etiologies of TTP other than acquired severe ADAMTS13 deficiency include drug-induced syndromes, most commonly caused by quininedependent antibodies and Shiga toxin, resulting from enterohemorrhagic infection with E coli 0157:H7. In addition, some patients with clinically diagnosed TTP are subsequently recognized to have an alternative disorder that mimicked the presenting clinical features of TTP, such as severe preeclampsia, malignant hypertension, a systemic infection, or occult malignancy. Finally, some patients in the Oklahoma TTP-HUS Registry have had an established SLE diagnosis; we describe these patients as having both SLE and TTP, but we recognize that accurate diagnosis of these patients is difficult.

A longitudinal study of parental discipline of young children.

Abstract: OBJECTIVE To determine how discipline practices changed over time for young children. METHODS A cohort of parents with young children were interviewed in clinic about a broad array of disciplinary practices at two points in time. RESULTS A total of 182 parents were interviewed at Time 1, and 94 were interviewed at Time 1 and 2. Mean age of the child was 16.2 months at Time 1 and 35.8 months at Time 2. Monitoring, verbal communication, and distracting were the most common types of discipline when the children were one year old. Corporal punishment (P < 0.05), verbal communication (P < 0.001), timeout (< 0.0001), removing privileges (< 0.0001), negative demeanor (< 0.0001), and sternness (< 0.0001) increased significantly from Time 1 to Time 2. Distracting (< 0.001) decreased significantly and positive demeanor also decreased. CONCLUSIONS Most discipline practices increased in frequency over the 20 months of this study. The increase in parental negative demeanor seems particularly important and worthy of further study.

Prosthetic joint infection by Mycobacterium tuberculosis: an unusual case report with literature review.

Abstract: Prosthetic joint infection with Mycobacterium tuberculosis usually involves the hips or knees and can result from either local reactivation, or less often from hematogenous spread. Predisposing conditions include rheumatoid arthritis, chronic steroid use and pulmonary diseases. The most common symptom at presentation is pain, and the most common physical finding is joint swelling and/or a draining sinus tract. The sedimentation rate is helpful when elevated but is nonspecific, and initial skin testing is only helpful when positive. The diagnosis depends on culture and histologic examination of tissue. Removal of the joint combined with oral antituberculous treatment is necessary when the infection is discovered greater than six weeks post joint replacement. Early diagnosis leads to decreased morbidity. Tuberculous infection of prosthetic joints is a rare disease and its diagnosis depends on a high degree of clinical suspicion.

Small bowel capsule endoscopy: a systematic review.

Abstract: Wireless capsule endoscopy offers a revolutionary diagnostic tool for small bowel diseases Since its formal introduction, it has become an integral part of the diagnostic evaluation for obscure gastrointestinal bleeding This relatively noninvasive imaging modality offered by small bowel capsule endoscopy is appealing to both patients and providers and consequently, the desire to expand its diagnostic role continues to grow The use of CE in the diagnosis of Crohn disease and chronic diarrhea is being further investigated, as is the potential of employing this technique as a cancer surveillance mechanism in patients with hereditary polyposis syndromes which may involve the small bowel This review article discusses the current indications for small bowel capsule endoscopy, the results of capsule endoscopy in patients with obscure gastrointestinal bleeding and small bowel diseases, and patient outcomes following capsule endoscopy Capsule endoscopy is compared with traditional diagnostic modalities, including small bowel series, enteroclysis, CT, and push enteroscopy Small bowel capsule endoscopy is the procedure of choice to evaluate obscure gastrointestinal bleeding, and is superior to radiographic procedures in detecting Crohn disease of the small bowel

The history of lupus erythematosus.

Abstract: This article explores the history of lupus erythematosus from the origins of the name to the most modern therapeutic advances. The review includes information about the origin of the name "lupus," the first clear description of the skin lesions, the discovery of the systemic and discoid forms, and further advances which define our current view of this illness. The classical descriptions of Hippocrates, Paracelsus, Manardi, Rudolph Virchow, Cazenave, Robert Willan, and Moritz Kaposi are chronologically described. Later, the contributions of Sir William Osler, Jonathan Hutchinson, Sequira and Balean, Kraus and Bohac, Libman and Sacks, Malcolm Hargraves, and Edmund L. Dubois are highlighted. The major breakthroughs of the modern period, including the diagnostic tests, animal models, and genetics, are briefly described. The article ends with the history of drug-induced lupus, diagnostic criteria, and the history of the therapy of lupus erythematosus. With modern therapeutic advances, the mortality rate from lupus erythematosus has decreased substantially. It is hoped that current research will further improve the prognosis of this disease in the near future.