Metastatic Crohn's disease: case report of an unusual variant and review of the literature.

PURPOSE: Metastatic Crohn's disease is a rare complication of Crohn's disease that has been infrequently reported in the literature. We report a case where submammary, inguinal, and perineal disease was observed in a patient many years after a proctocolectomy. The proliferative and polypoid morphology of the cutaneous lesions has not been previously described. In addition, this case describes severe cutaneous metastatic Crohn's disease in the absence of active gastrointestinal disease, which to our knowledge has not been reported in the literature. RESULTS: A 55-year-old female with a 25-year history of Crohn's disease was investigated and treated over a 12-month period for metastatic Crohn's disease involving the submammary, inguinal, and perineal areas. These proliferative lesions with erythema and ulceration were histologically consistent with metastatic Crohn's disease. Gram and Ziehl Nielsen stains revealed no pathogenic organisms. The use of topical solutions, antibiotics, immunosuppression, and surgery failed to produce any significant benefit. A review of 42 cases of metastatic Crohn's disease in the literature is reported. CONCLUSION: Cutaneous metastatic Crohn's disease has an extremely variable macroscopic appearance and may be a source of considerable morbidity. It can be present without other significant symptomatology, although it more commonly parallels gastrointestinal disease activity. There are no trials to guide current treatment, which is mainly based on anecdotal reporting.

English-only work rules: balancing fair employment considerations in a multicultural and multilingual healthcare workforce.

Most healthcare organizations are currently or will shortly be composed of a multicultural and multilingual workforce. In attempting to manage such diverse workforces. English-only work rules may be necessary to ensure effective communication among workers. However, care must be taken to insure that the employees' rights to free speech and a harassment-free workplace are not infringed by utilizing English-only work rules. This article attempts to assist the healthcare manager in dealing with the legal aspects of English-only work rules. Specifically, an examination of two legal cases is provided to illustrate the various legal aspects of such work rules. Also, suggestions are offered as to how and when, or when not, to implement English-only work rule in order to avoid possible liability.

Meigs' syndrome in association with a locally invasive adenocarcinoma of the fallopian tube.

A patient with recurrent pleural effusions posed a diagnostic challenge. The pleural aspirate CA-125 assay was markedly elevated which indicated a primary ovarian pathologic process. However, in this case a rare fallopian tube adenocarcinoma was the underlying problem. Meigs' syndrome can resemble a metastatic pelvic carcinoma in its presentation, but the prognosis is much more favourable when the syndrome is associated with a benign ovarian tumour.

Employee participation programs in the health care industry: are they unlawful under recent labor rulings?

Two recent National Labor Relations Board decisions, Electromation and DuPont, may very well be used to declare many health care organizations' employee empowerment and participation programs (including TQM and CQI groups) in violation of U.S. labor laws. This article provides a detailed explanation of the NLRB's two-part inquiry that will now be used to determine whether a health care institution's employee participation programs are under the NLRB's jurisdiction as a labor organization, and if so, whether the institution is engaged in unlawful employer domination. This article will also provide guidance from the NLRB as to what form of employee participation may be permitted under the National Labor Relations Act.

Two cases of idiopathic acute gastric necrosis.

Two cases of acute hemorrhagic gastric necrosis are presented. The first patient was a 62 yr old man with a past history of chronic gastritis, Parkinson's disease and dementia. The second case was a 25 yr old woman with recent abuse of oral analgesic agents. Both presented with an acute abdomen and peritonitis, and underwent urgent gastrectomy for gastric necrosis with perforation. The first patient died, whereas the second recovered. Histology of the gastrectomy specimens showed severe hemorrhagic transmural gastric necrosis with minimal inflammatory changes. Only occasional Gram positive rods were seen in case 1, and microbiological cultures were negative. The etiology of the gastric necrosis in these 2 cases is unclear.

Sexual harassment at work: issues and answers for health care administrators.

Sexual harassment is not new to the health care industry. What is new is that recent media attention has heightened awareness that sexual harassment is illegal. This fact, coupled with the substantial liability that employers may incur if they fail to control sexual harassment, mandates the need for outlining the major issues relative to sexual harassment in today's health care setting. This article gives particular emphasis to the fact that sexual harassment can be prevented by taking a proactive stance.

A retrospective study of the Swanson great toe hemi-prosthesis.

This work is the summation and analysis of data received from a questionnaire forwarded to all Board Certified podiatric surgeons regarding their experience with the Swanson great toe hemi-prosthesis. The responses pertaining to a variety of concerns, including erosive changes, years in vivo, signs and symptoms indicating retrieval, percentage of surgeons polled performing retrieval and perceived reasons for observed erosive changes, were recorded and analyzed. The resultant data reveal significant erosive changes occur early after implantation with a plateau effect within 3 years. Persistent pain following implantation was the most common reason for removal followed by limited range of motion and nonspecific swelling. These three concerns comprised 70% of the reasons for retrieval followed by 18 other cited problems. The results of this poll originate from subjective and objective impressions of surgeons. It is clear that further work is required to scientifically identify and document the specific reasons for these findings, including the circumstances that result in successful implantation of this prosthesis.

The role of manometry, electromyography and radiology in the assessment of faecal incontinence.

The results of laboratory investigations in 156 patients presenting with faecal incontinence are reviewed to see if and how these investigations supplement a careful clinical evaluation, and in particular to see if they help in the practical management of the problem. All patients underwent anal manometry, and in addition 52 underwent anal sphincter electromyography and 27 defaecatory proctography. Anal manometry quantified sphincteric weakness, and proved superior to digital assessment in this regard. Resting and squeeze pressures were less in those with complete than those with partial incontinence but the differences were not statistically significant. The measurements of rectal sensation and compliance were not additionally helpful. Single fibre electromyography provided the best measure of denervation with re-innervation and was abnormal in about 85% of the group studied. Jitter studies were unhelpful. Most patients had some abnormality on defaecatory proctography but clinical significance could not be established. The choice of treatment was made on clinical grounds and was not influenced by these investigations.

The role of manometry, electromyography and radiology in the assessment of intractable constipation.

An analysis is made of functional studies performed in 96 constipated patients to see how these studies influenced the choice of surgical treatment. All patients underwent anal manometry, and other investigations included colonic transit studies (56), anal sphincter electromyography (42) and defaecatory proctography (34). Additionally nine patients underwent full thickness rectal biopsy. The resting anal canal pressures of the patients studied were lower than controls, and fibre density studies on electromyography were abnormal in half the patients studied suggesting a degree of denervation of the sphincter muscles, which possibly related to chronic straining on the toilet. There was evidence of reduced rectal sensation as shown by an increase in the least perceived volume on balloon distension of the rectum, and in those with megarectum and/or megacolon an increase in maximum tolerated volume. The recto-anal inhibitory reflex was used to screen for adult Hirschsprung's disease, but in one patient the reflex was present despite absence of ganglia on full thickness rectal biopsy indicating the need for biopsy as the definitive diagnostic procedure. Delayed colonic transit using radio opaque markers was a necessary requirement before recommending colectomy, and delayed transit was demonstrated in 34% of the patients studied. Anismus on electromyography was found in 20% of the patients but there was poor correlation with failure of the anorectal angle to widen when bearing down on proctography. The investigations helped in the choice of treatment, but were difficult to interpret. They should be used in severe constipation when surgery is being contemplated.

Correlation between injury severity scores and subjective ratings of injury severity: a basis for trauma audit.

A retrospective review of 1900 road accident victims attending the emergency departments of two Melbourne hospitals was undertaken to identify Injury Severity Score levels which could distinguish between minor, moderate, severe and critical injury. Injuries scoring ISS 6 or below were designated 'minor' because they were associated with a low risk of requiring admission to hospital. Case notes of patients scoring above ISS 6 were then reviewed by a panel of clinicians, who independently rated each patient's overall injury severity as moderate, severe or critical according to what was recorded in the notes and their 'clinical' judgement. ISS values were compared with clinicians' ratings. Measures of each clinician's individual rating consistency, and correlation between pairs of clinicians with respect to inter-rater consistency, were made. By combining data from both hospitals it emerged that 'moderate' injury corresponded to ISS 8-13, 'severe' to ISS 14-20 and 'critical' to ISS 21 and above. These ISS breakpoints will be useful in selecting groups of injured patients for future trauma audit studies.

The politics of cutback management.

Health and social service organizations in the United States are experiencing decline in financial resources. Little is known about the management of such decline. Forty-three executives of health and human service organizations were interviewed to study their experience with cutback management. The political strategies used by the executives to cope with cutbacks are described.

Renal impairment and its reversibility following variable periods of complete ureteric obstruction.

There is debate concerning the time course and degree of recovery possible after relief of complete unilateral ureteric obstruction. This study in dogs investigates these features. One ureter was occluded for varying periods, and then reimplanted into the bladder. Recovery was monitored by Tc-Sn-labelled diethylene triamine penta acetic acid (D.T.P.A.) scans and renograms together with creatinine clearance studies. The morphological changes were also studied. There was found to be a progressive loss of functional recovery with increasing periods of obstruction, though this was dramatically improved by contralateral nephrectomy once recovery had stabilized. Increased radial scarring developed in the kidney following increasing periods of obstruction.

The role of bradykinin in endotoxic shock of intestinal origin.

A relationship was looked for between blood levels of bradykinin and endotoxaemia produced by superior mesenteric artery occlusion in the rabbit. The levels of bradykinin were unrelated to and unaltered by the degree of endotoxaemia observed in the systemic and portal circulations. These findings suggest that bradykinin is not responsible for the release of endotoxin from the gut, or the circulatory collapse which follows.