Tuberculous cerebellar abscess.

BACKGROUND: Tuberculosis is an important illness with an increasing occurrence. Although considered primarily a pulmonary disease, tuberculosis can affect any organ system. Central nervous system involvement is potentially devastating and occurs with escalating frequency in both immunocompetent and immunologically incompetent populations. METHODS: This case report involved a patient admitted to the authors' inpatient service. Data were obtained from the patient's medical record. MEDLINE and Index Medicus literature searches were conducted for the years 1977 to the present, with cross-references for earlier articles. RESULTS AND CONCLUSIONS: A 36-year-old previously healthy, immunocompetent woman with a diagnosis of extrapulmonary tuberculosis and no determined primary focus was found to have a cerebellar abscess. Treatment included surgical excision of the abscess combined with 6 months of antituberculosis therapy. Diagnostic tools included the tuberculosis skin test, smears and culture of specimens, computed tomographic scans, and rapid assays based on nucleic acid amplification, ie, polymerase chain reaction. The polymerase chain reaction has great potential for rapid diagnosis of Mycobacterium tuberculosis, particularly when there might be few bacilli, as in pleural, peritoneal, or cerebrospinal fluid. Appropriate therapy for tuberculous cerebellar abscess includes standard antituberculosis medications for 6 to 9 months and surgical excision of the abscess.

Family practice house officer perceptions of faculty teaching behaviors.

In 1985, Wolverton and Bosworth published an often referenced study of family practice teaching behaviors. Their research identified 20 "most helpful" and 10 "least helpful" behaviors. In 1994 all United States Army family practice house officers were asked by survey to rate each of the original 38 Wolverton and Bosworth teaching behaviors as "not at all helpful," "somewhat helpful," "moderately helpful," "very helpful," or "most helpful" in aiding their learning. Mean values were calculated for each teaching behavior. Twenty most helpful and 10 least helpful faculty teaching behaviors were identified for U.S. Army family practice house officers; several differences were identified in comparison with Wolverton and Bosworth's original study. Additionally, three most helpful and four least helpful teaching behaviors were clearly illuminated. Incorporating the results of this new study into residency programs could improve the learning opportunities afforded family practice house officers during their internships and residencies.

Army family practice: does our training meet our needs?

OBJECTIVES: (1) To determine the perceived adequacy of residency training for current practice by Army family physicians; (2) to ascertain if differences exist by residency setting: medical center, medical activity, or civilian. METHODS: Surveys were mailed to the 334 family physicians in the Army in 1993. Training in various subject areas was rated as inadequate, adequate, or overly prepared. RESULTS: More than 75% of respondents felt prepared in 76% of general medical subjects (GM) but in only 39% of family medicine subjects (FM). There were no practice management subjects in which more than 75% felt adequately prepared. There were no differences in perceptions of GM or FM training between military- and civilian-trained respondents. CONCLUSIONS: Army and civilian residencies prepare family physicians for the medical aspects of practice. Early training in management subjects could be enhanced. Civilian and Army programs could improve training in family medicine subjects.

Clostridium difficile colitis presenting as an acute abdomen: case report and review of the literature.

Pseudomembranous colitis associated with Clostridium difficile rarely manifests as an acute abdomen and even more rarely as an acute abdomen without abnormal radiologic studies. The following is a case report of a 52-year-old white man who had an acute abdomen without abnormal radiologic studies, and was given a final diagnosis of C difficile colitis. Surgery was averted only by the ability to do an expeditious flexible sigmoidoscopy with the visualization of pseudomembranes. Diagnosis was later confirmed by a positive toxin assay and culture of C difficile. Treatment for C difficile colitis is usually medical, with oral vancomycin the preferred agent. Surgery may be needed when there is an acute abdomen with other systemic signs (fever or leukocytosis) or abnormal radiologic studies.

Retiree awareness of levels of blood pressure and cholesterol.

PURPOSE: Determine the level of awareness of cholesterol and blood pressure in a retiree population; assess factors indicating a higher risk for lack of awareness. METHODS: A cross-sectional survey was mailed to a random sample of 9.5% of the 7,400 retiree households served by an Army community hospital. Data analysis used descriptive statistics and t test for continuous data and chi-square for categorical data. RESULTS: Response rate was 71.4%. Overall, 45.8 and 37.9% of the respondents have accurate knowledge of the levels of their blood pressure and cholesterol, respectively. For those with documented hypertension and hyperlipidemia, the correct awareness levels are 78.5 and 63.4%, respectively. The only sociodemographic factor associated with correct awareness is age with cholesterol knowledge. CONCLUSIONS: This population meets the objectives set by Healthy People 2000 for cholesterol awareness, but not for blood pressure. The overall levels of awareness compare favorably to results from other studied populations. Physicians are not using all opportunities to educate patients about modifiable risk factors.

Perceptions of teaching behaviors by primary care and non-primary care residents.

PURPOSE: To ascertain the most helpful and least helpful faculty teaching behaviors as perceived by primary care and non-primary care residents and to assess differences in those perceptions between the two resident groups. METHOD: A cross-sectional mailed survey was undertaken in 1993-94 of all 1,046 residents (including interns) in U.S. Army graduate medical education programs. The survey asked the residents to rate the 38 teaching behaviors of Wolverton and Bosworth. Mean ratings were calculated for each teaching behavior, and the ratings of the two resident groups were compared using Kendall's coefficient of concordance. RESULTS: In all, 490 (47%) of the residents responded: 191 (45%) of 421 in primary care, and 299 (48%) of 625 in non-primary care. The primary care and non-primary care groups had a high degree of concordance in ranking of the 38 teaching behaviors (W = .953). The exact rank orders differed slightly, but there was disagreement on only one behavior each within the rankings of both the ten most helpful and the ten least helpful behaviors. CONCLUSION: Army residents in all of the major specialties have similar perceptions of what they consider helpful behaviors from their faculty.

The practice of obstetrics by Army family physicians.

BACKGROUND: There has been a dramatic decline nationwide in family physicians practicing obstetrics. This study describes the practice of obstetrics by Army family physicians in an environment relatively free of malpractice liability and other financial concerns. METHODS: A questionnaire was mailed to every family physician on active duty in the Army (n = 334) in 1993, with a final response rate of 79 percent (n = 265). RESULTS: Nearly 73 percent of Army family physicians practice obstetrics. Almost all believed they were adequately prepared to provide routine prenatal care (98 percent) and complicated obstetric care (84 percent). More than 95 percent of those assigned to a teaching facility delivered babies. Obstetric procedures that the majority performed included normal vaginal deliveries (100 percent), repair of third-degree (98 percent) and fourth-degree (93 percent) tears, insertion of fetal scalp electrodes (96 percent) and intrauterine pressure catheters (98 percent), interpretation of nonstress tests (97 percent) and contraction stress tests (83 percent), vacuum extractions (93 percent), pudendal or paracervical blocks (88 percent), first assist in Cesarean sections (80 percent), amnioinfusions (76 percent), and low-forceps deliveries (53 percent). Those who currently practice obstetrics were more satisfied with being a family physician compared with those who did not practice obstetrics (95 percent vs 86 percent, P < 0.02). CONCLUSIONS: The majority of Army family physicians perform a wide spectrum of obstetrics care. Those who practiced obstetrics were generally more satisfied with family practice than were those who did not practice obstetrics.

Exercised-induced hematuria.

Bloody or discolored urine after exercise can have various etiologies. Exercise-induced hematuria is a common, benign cause of discolored urine following strenuous exercise. Evaluation of patients with this complaint begins with a thorough history, a focused physical examination and a microscopic examination of the urine. Using a systematic approach, the physician can detect serious, treatable problems, and testing can be limited. Patients with exercise-induced hematuria can be reassured that the condition is benign and that they can return to full activity.

Pseudotumor of infancy and congenital muscular torticollis.

Pseudotumor of infancy presents as a discrete, firm mass in the distal sternocleidomastoid muscle in infants two to four weeks of age. Congenital muscular torticollis may develop from the resultant fibrosis in 10 to 20 percent of cases. Hip dysplasia is an associated feature of congenital muscular torticollis in approximately 10 percent of cases. Pseudotumor of infancy must be differentiated from other causes of cervical soft tissue masses. Diagnostic choices include fine-needle aspiration biopsy, cervical radiography, ultrasonography, computed tomographic scanning of the head and neck, and magnetic resonance imaging. Left untreated, congenital muscular torticollis may lead to significant craniofacial asymmetry and scoliosis. Heat, massage and passive stretching exercises are the preferred initial treatments for pseudotumor and torticollis. More than 70 percent of patients will respond to this approach. Surgery should be reserved for treatment of cases that persist past the first year of life.

Clonidine-induced bradycardia.

Clonidine is an alpha-adrenergic agent that is used in the treatment of hypertension. Bradycardia has been described as a common effect of clonidine poisoning, but has rarely been described as a side effect at commonly prescribed dosages. Bradyarrhythmias, as a side effect, may have several manifestations and may be symptomatic or asymptomatic. This report proposes mechanisms for clonidine-induced bradycardia, describes persons at risk for this effect, and outlines treatments and preventive measures.

Army family physician satisfaction.

INTRODUCTION: As numbers of family physicians decrease in the Army, the Army needs to know how satisfied they are with being family physicians and military officers. What variables are associated with these satisfactions? METHODS: This was a cross-sectional mailed survey of Army family physicians (N = 334). The response rate was 82% (N = 274). The survey included questions with a Likert scale and was analyzed using Kruskal-Wallis, one-way analysis of variance, and logistic regression. RESULTS: Ninety-two percent were satisfied with being family physicians and 74% were satisfied with being military officers. The variables associated with satisfaction were rank (positively associated) and percent time in patient care (negatively associated). CONCLUSIONS: Army family physicians are more satisfied with being family physicians than they are with being military officers. They are, however, satisfied with both professions. The Army, as an organization, may want to explore how its system of rewards interplay with rank and amount of time in patient care to make them predictive of satisfaction.

Effect of terbutaline tocolysis on infant birthweight.

BACKGROUND: Previous research has suggested that terbutaline sulfate increases serum glucose in pregnant women. Increases in serum glucose in women who have gestational diabetes mellitus often lead to the birth of larger infants. This study examines the effect on infant birthweight of terbutaline used as a tocolytic agent in otherwise normal term pregnancies. METHODS: An historical cohort study was conducted of all births in a 12-month period at a US Army community hospital. There were 1376 deliveries of all types; 481 of the patients were excluded for variables that influence gestational duration or fetal weight, and 5 patients' records were lost. Birthweights relative to gestational age were compared. RESULTS: The two groups (women who were treated with terbutaline, n = 94; control group, n = 796) differed with respect to age (terbutaline group, 1.6 years younger, P = .002); pregravid weight (terbutaline group, 10.3 lb lighter, P < .001); and total weight gain (terbutaline group, 3.2 lb less, P = .001). The groups were comparable in all other variables studied (P > .05). Women receiving terbutaline therapy (average length of therapy, 4.7 weeks) gave birth an average of 1 week earlier than those not treated with terbutaline (39.09 weeks and 40.09 weeks, respectively, P < .001). The mean absolute birthweight of infants exposed to terbutaline in utero was less than that of infants from the control group (P < .001), but this difference (191.6 g) can be accounted for by the difference in average gestational age between the terbutaline group and the control group. There was no difference in birthweight (P > .05) when birthweight relative to gestational age was compared between the two groups. CONCLUSIONS: Women in this study who were treated with terbutaline did not give birth to larger infants. The previously noted hyperglycemia in women receiving terbutaline may not have been present in this study population or may not have been significant enough to affect birthweight.

Military hospital closure and local retirees.

PURPOSE: We assessed the demographics of the retiree population in the catchment area of a military hospital scheduled for closure under base realignments and closures (BRAC) round II. The purpose was to define their health care needs and their perceptions on health care after hospital closure. METHODS: A randomized mail survey was done of 9.5% of the retiree households in the catchment area of Hays Army Hospital at Fort Ord, California. Areas assessed were sociodemographics, activities of daily living, general health status, and perceptions of medical services. Response rate was 75%. RESULTS: This population is predominantly young, married, and in relatively good health. However, they perceive that they are not in good health and future prospects are that they will have higher health needs. CONCLUSIONS: This population appears to be poorly informed on their options for health care and how to pay for it outside the military system. The Department of Defense should address these issues at the system level rather than at the local hospital level.

A comparison of the content of army family practice with nonfederal family practice.

BACKGROUND: To assist with planning for education and practice, family physicians should know the practice content of their practices. The present study compared the content of nonfederal family practice with Army family practice to explore their differences. METHODS: This was a secondary analysis that compared the similar variables within two national data sets: The National Ambulatory Medical Care Survey and the Army's Ambulatory Care Data Base. RESULTS: Army patients were younger and more likely to be female than were nonfederal patients. Army family physicians spent more time with patients in all groups than did nonfederal family physicians. While 12 of the top 20 diagnosis clusters of each sector were the same, there were differences found in the percentages of total visits contained within the top 20 clusters. CONCLUSIONS: Both nonfederal and Army family practice have a wide variation in patients and diagnoses. The two sectors are different in patient age and the frequency of different diagnoses. Knowledge of these differences can assist with planning.

Treatment approaches to bruxism.

Bruxism, or the grinding and clenching of teeth, occurs in approximately 15 percent of children and in as many as 96 percent of adults. The etiology of bruxism is unclear, but the condition has been associated with stress, occlusal disorders, allergies and sleep positioning. Because of its nonspecific pathology, bruxism may be difficult to diagnose. In addition to complaints from sleep partners, signs of teeth grinding include masticatory pain or fatigue, headaches, tooth sensitivity and attrition, oral infection and temporomandibular joint disorders. Signs of bruxism include tooth wear and mobility, as well as tender or hypertrophied masticatory muscles and joints. Children with bruxism are usually managed with observation and reassurance. Adults may be managed with stress reduction therapy, alteration of sleep positioning, drug therapy, biofeedback training, physical therapy and dental evaluation. If significant tooth attrition, mobility or fracture occurs, dental referral is mandatory.

Nutritional status of rural Bolivian children.

While providing health care in rural Bolivia, 349 children under 4 years old were seen. Height and weight were measured and demographic data obtained. The purpose was to describe the prevalence of malnutrition and its associated socioeconomic factors. The sample included Mataco Indians and Bolivians of European or of mixed descent. Using international standards, 21% of the children had weight below the fifth percentile for age; 27% had height below the fifth percentage for age; 17% were below the fifth percentile for weight/height. Malnutrition was more common in younger children (peak prevalence in 1-2 year olds). Malnutrition was associated with race and water source, but not with family size, literacy, immunizations, meals per day, or deaths in family. Attempts to improve nutrition should focus on the youngest children.

PIP: The authors measured height and weight and obtained demographic data for 349 children under 4 years of age in rural Bolivia for the purpose of describing the prevalence of malnutrition and its associated socioeconomic factor. The sample included Mataco Indians and Bolivians of European or of mixed descent. On the basis of international standards, 21% had weight below the 5th percentile for age; 27% had height below the 5th percentile for age; and 17% were below the 5th percentile for weight/height. Malnutrition was most common in younger children, with a peak prevalence among 1-2 year olds. Malnutrition was associated with race and water source, but not with family size, literacy, immunizations, meals per day, or deaths in the family. These findings suggest that attempts to improve nutrition should focus on the youngest children.

Caring for the bicultural family: the Korean-American example.

Bicultural families are increasing in US society, and family physicians will see more of these families for medical care. They can exhibit problems unique to their bicultural experience that arise from the stresses caused by cultural differences in such areas as family roles, emotion expression, child rearing, interpersonal relationships, and methods of communication. If coping mechanisms do not resolve these stresses, the family will come to the family physician with physical manifestations of illness or distress. The symptoms are usually related to depression or depressive equivalents. To care for these families successfully, family physicians should treat both family members and the individual patient. When caring for bicultural families, it is important to recognize the high-risk factors that put them at risk for dysfunction. Treatment goals should be centered on communication and education. In short-term counseling, support, education, listening, and referral to appropriate community resources are useful treatment modalities.

A description of the content of army family practice.

BACKGROUND: For decisions about residency curricula and downsizing the US Army medical corps, decision makers must know the practice content of the various specialties. Little is known about the content of Army family practice. The purpose of our study was to describe the content of Army family practice. METHODS: We analyzed a random sample of 28,849 family practice encounters from the US Army Ambulatory Care Data Base Study. Variables included patient demographics, diagnoses, visit duration, procedures, and medical facility. Patient age and visit duration were compared using analysis of variance; facility profiles were compared by age category and sex of patients, family member position, and procedure frequency using chi-square analysis. Diagnostic content of the facilities was compared by both chi-square and Kendall's tau B tests. RESULTS: The typical patient was a 26-year-old woman. The 25 most frequent diagnoses accounted for three-fourths of all encounters, with variation by patient age. The majority of visits did not include a procedure, but procedure frequency varied by patient age and diagnostic certainty. Mean visit duration was 16.4 minutes and varied by age. There were differences among the sites for all variables. CONCLUSIONS: Army family physicians see patients of all ages, of whom more are the family members of soldiers than the soldiers themselves; they frequently do procedures and are usually certain of their diagnoses, which include a broad spectrum of illnesses. Army family physicians are flexible, adapt to local patient and environmental needs, and are uniquely qualified to form the basis of Army medicine.

Family separations in the military.

Family separations are an intrinsic part of military life. The temporary loss of a family member through deployment brings unique stresses to a family in three different stages: predeployment, survival, and reunion. Most families adapt to these stresses well. In families without adequate coping skills, however, these stresses can lead to problems which the family presents to the health care system. Health care providers must be aware of these stresses, the high-risk families, their clinical manifestations, and techniques for preventing and treating them. This article provides some help for health care providers dealing with these issues.

A comparison of MEDRETE practice content to U.S. ambulatory care.

A U.S. military medical team spent 2 weeks providing medical care in a rural area in Bolivia. Records of presenting complaints and physician diagnoses were kept for 2,169 patients seen during the exercises. Patients seen in Bolivia were younger than in typical U.S. clinics, with 53% being less than 15 years old. Digestive system complaints were the reason for 35% of the visits, compared to 5% in U.S. clinics. Diagnoses made more often than expected on the Bolivian expedition included gastroenteritis, peptic diseases, low back pain, and headaches. Supply and personnel needs are greatly influenced by these patient characteristics.