Polymyalgia rheumatica and temporal arthritis.

Polymyalgia rheumatica and temporal arteritis are closely related inflammatory conditions that affect different cellular targets in genetically predisposed persons. Compared with temporal arteritis, polymyalgla rheumatica is much more common, affecting one in 200 persons older than 50 years. Temporal arteritis, however, is more dangerous and can lead to sudden blindness. The diagnosis of polymyalgia rheumatica is based on the presence of a clinical syndrome consisting of fever, nonspecific somatic complaints, pain and stiffness in the shoulder and pelvic girdles, and an elevated erythrocyte sedimentation rate. Temporal arteritis typically presents with many of the same findings as polymyalgia rheumatica, but patients also have headaches and tenderness to palpation over the involved artery. Arterial biopsy usually confirms the diagnosis of temporal arteritis. Early diagnosis and treatment of polymyalgia rheumatica or temporal arteritis can dramatically improve patients' lives and return them to previous functional status. Corticosteroid therapy provides rapid and dramatic improvement of the clinical features of both conditions. Therapy is generally continued for six to 24 months. Throughout treatment, clinical condition is assessed periodically. Patients are instructed to see their physician immediately if symptoms recur or they develop new headache, jaw claudication or visual problems.

Health issues in men: Part II. Common psychosocial disorders.

During screening examinations and, when appropriate, other health-related visits, family physicians should be alert for signs and symptoms of common psychosocial disorders in men. Health issues of concern include alcohol and substance abuse, domestic violence, midlife crisis and depression. Alcohol remains the most abused drug in America. The highest rates of alcohol abuse are in men 25 to 39 years of age, although alcoholism is also a considerable problem after 65 years of age. Disulfiram and the opioid antagonist naltrexone are the two medications currently labeled by the U.S. Food and Drug Administration for the treatment of chronic alcohol dependence. Like alcohol abuse, domestic violence is a sign of psychosocial distress in men. Domestic violence may be a problem in up to 16 percent of marriages. Most men move through the midlife period without difficulty. Major depressive illness occurs in about 1 percent of elderly men, whereas minor depression or subsyndromal depression affects 13 to 27 percent of older men. Selective serotonin reuptake inhibitors have become first-line therapy for depression.

Health issues in men: part I: Common genitourinary disorders.

Common genitourinary health issues that arise in the care of male patients include prostatitis, benign prostatic hyperplasia, urogenital cancers, premature ejaculation and erectile dysfunction. Bacterial infections are responsible for only 5 to 10 percent of prostatitis cases. Benign prostatic hyperplasia is present in 90 percent of men by the age of 85. Common urogenital cancers include prostate cancer, transitional cell carcinoma of the bladder and testicular cancer. Although an estimated 10 percent of men eventually develop prostate cancer, screening for this malignancy is one of the most controversial areas of health prevention. Premature ejaculation occurs in as many as 40 percent of men. Treatment with tricyclic antidepressants, selective serotonin reuptake inhibitors, counseling or behavioral therapy may be helpful. Erectile dysfunction affects up to 30 percent of men between 40 and 70 years of age. Stepped therapy is a useful approach to this common malady. Good treatment results have been obtained with orally administered sildenafil and intraurethrally administered alprostadil.

Acute and post-traumatic stress disorder after spontaneous abortion.

When a spontaneous abortion is followed by complicated bereavement, the primary care physician may not consider the diagnosis of acute stress disorder or post-traumatic stress disorder. The major difference between these two conditions is that, in acute stress disorder, symptoms such as dissociation, reliving the trauma, avoiding stimuli associated with the trauma and increased arousal are present for at least two days but not longer than four weeks. When the symptoms persist beyond four weeks, the patient may have post-traumatic stress disorder. The symptoms of distress response after spontaneous abortion include psychologic, physical, cognitive and behavioral effects; however, patients with distress response after spontaneous abortion often do not meet the criteria for acute or post-traumatic stress disorder. After spontaneous abortion, as many as 10 percent of women may have acute stress disorder and up to 1 percent may have post-traumatic stress disorder. Critical incident stress debriefing, which may be administered by trained family physicians or mental health practitioners, may help patients who are having a stress disorder after a spontaneous abortion.

Varicella susceptibility and vaccination strategies in young adults.

BACKGROUND: Varicella infection causes substantial morbidity in young adults. Most military basic trainees are 18 to 21 years old, yet the Army has no varicella vaccination policy. We therefore determined varicella susceptibility in a population of Army basic trainees, examined variables that might predict antibody status, and developed a vaccination strategies model. METHODS: Fifteen-hundred ninety-five trainees completed a demographic and historical questionnaire. Varicella antibody status was determined on 1201 volunteers. These data plus information from the literature were used to construct a decision tree of vaccination strategies that was applied to the total population of Army basic trainees in 1995 (n = 65,298). RESULTS: Fifty (4.2 percent) of 1201 soldiers were antibody negative. Trainees who lived with no or 1 sibling while growing up were most likely to be seronegative (P < 0.01). The positive predictive value of a history of varicella was 98.5 percent, whereas the negative predictive value of a negative history of varicella was 23 percent. In the vaccination strategies model, serologically testing soldiers with a negative history of varicella and vaccinating those without protective antibodies was the most cost-effective approach. CONCLUSIONS: In young adults a positive varicella history accurately predicts immunity, but verification of a negative history with antibody testing is recommended before vaccination.

Medical support for Operation Cooperative Nugget '95: joint readiness training in the post-cold war era.

The purpose of this paper is to report the demographic characteristics, injury and illness profiles, and dispositions of patients seen at the 249th General Hospital during its month-long deployment in support of Operation Cooperative Nugget '95 at the Joint Readiness Training Center (JRTC), Fort Polk, Louisiana. A descriptive analysis of patient demographic, diagnostic, and disposition data was performed. A total of 769 patient contacts were made, with orthopedic injuries (31%), dermatologic disorders (17%), upper respiratory infections (6%), and heat injuries (5%) accounting for the majority of visits. Because of aggressive preventive medicine interventions, there were no cases of heat stroke despite daily heat indices of 110 to 120 degrees F. In addition to emphasizing the importance of anticipating environmental medical threats, the authors relate some lessons learned, which should be valuable to medical providers tasked for future multinational operations other than war at the JRTC and elsewhere.

Evaluation of pediatric foot problems: Part II. The hindfoot and the ankle.

The bony development of the growing child can lead to a variety of hindfoot and ankle problems. Overuse injuries are common, often occurring in conjunction with symptomatic pes planus and plantar fasciitis. Predisposing structural differences such as Haglund's disease, os trigonum, rigid and flexible pes planus, and Sever's disease merit special attention, but treatment may require only patient education and conservative management. Sprains and fractures of growing joints, however, may have poor outcomes if ignored or missed.

Evaluation of pediatric foot problems: Part I. The forefoot and the midfoot.

Foot problems in children can be the result of infection, trauma or overuse. Ingrown toenails, bunions, sesamoid disease, congenital overriding of the fifth toe, and fractures may occur in both adults and children. Some disorders, such as Freiberg's infarction and Kohler's disease, however, are unique to the pediatric population. The potential for adverse sequelae is greater in children than in adults. A thorough understanding of the anatomy of the pediatric foot and a systematic examination will facilitate the diagnosis of pediatric foot problems. A conservative approach to management will improve both compliance and outcome.

Counseling patients on proper use of condoms.

The best condoms are made of latex, are lubricated and coated with a spermicide, and have a reservoir tip. Condoms can protect against conception and sexually transmitted diseases, including acquired immunodeficiency syndrome. When condoms are used properly and in combination with vaginal spermicidal foam, the contraceptive failure rate is as low as 1 percent. Failure is more often due to user error than product defect. Recommendations for the proper use of condoms are presented.

A hazardous side effect of neuroleptics: diagnosis and treatment.

Neuroleptic malignant syndrome (NMS) is a potentially fatal disease process characterized by hyperthermia, altered mental status, muscular rigidity, and autonomic instability. This syndrome is most often seen in patients who are taking neuroleptics and other psychoactive medications. Primary care physicians are often the first providers to see patients with this syndrome and must be alert to its potential diagnosis. Treatment should be immediate and consists of discontinuing the neuroleptic medication; supporting pulmonary, cardiovascular, and renal functions, and using bromocriptine and/or dantrolene.

New trends in the management of peritonsillar abscess.

Peritonsillar abscess is the most common complication of acute tonsillitis. Signs and symptoms include fever, unilateral sore throat, odynophagia and trismus. Optimal management consists of antibiotic therapy and drainage of the abscess. Controversy exists about the drainage procedure, which includes needle aspiration, incision and drainage, or acute tonsillectomy. Data indicate that outpatient needle aspiration, antibiotics and pain medication are effective treatment in 85 to 90 percent of patients with uncomplicated peritonsillar abscesses.

The physical effects of lightning injury.

Several thousand lightning-related injuries occur each year in the United States resulting in nearly 600 deaths. Most incidents involve individual victims; group lightning strikes are rare. Ten soldiers were simultaneously injured in a group lightning strike while on training maneuvers at Fort Benning. Georgia. No deaths or loss of consciousness occurred, although two of the soldiers had amnesia for the event. All of the soldiers were hospitalized and observed for potential lightning-related complications. Ninety percent of the soldiers had first-degree skin burns, and all had focal muscular tenderness. Seventy percent had transient ST segment elevation that resolved. Fifty percent developed creatinine kinase (muscular component) elevation, but none developed myoglobinuria or acute renal failure. No patient had creatinine kinase (myocardial component) elevation. Transient hypertension and tinnitus were noted in 40% and 20%, respectively. No compartment syndromes or ocular manifestations developed. All 10 soldiers recovered uneventfully and returned to full active duty.

Efficacy of routine postpartum uterine exploration and manual sponge curettage.

Many physicians feel that manual exploration and sponge curettage of the uterus should be a routine part of all vaginal deliveries. Three hundred twenty uncomplicated routine vaginal deliveries (185 with exploration and sponge curettage, 135 without) were prospectively analyzed for differences in outcome with regard to postpartum hemorrhage, postpartum infection, and the patient's perception of pain. Results revealed there to be no clinically or statistically significant difference between these two groups in postpartum bleeding, postpartum white blood cell counts, and postpartum fever during the three-day postdelivery hospitalization. All patients were followed for six weeks. Five of 185 patients (2.7 percent) in the explored group returned for postpartum bleeding complications, one requiring hospital admission. Three of 135 (2.2 percent) returned for postpartum bleeding in the unexplored group, none requiring hospital admission. No patients in either group had complications with postpartum endometritis in the follow-up period. The patient's perception of pain was significantly higher in the explored and curettaged group as opposed to the unexplored group (P less than .0002). This study reveals that routine elective postpartum manual exploration and sponge curettage of the uterus is a painful procedure that is not clinically indicated for reducing the potential risk of postpartum hemorrhage or endometritis and is unnecessary following routine vaginal delivery.

Vacuum extraction.

Vacuum extraction rivals forceps delivery in efficacy, is less traumatic to the mother and is as safe or safer than forceps delivery for the infant. Soft plastic cup extractors minimize the technical, maternal and fetal problems of vacuum extraction and have made this method of delivery ideal for the family physician who practices obstetrics.