Urinary tract infection and pyelonephritis.

UTIs are common, potentially severe infections that the emergency physician must manage efficiently and effectively. In most cases, this entity is well recognized, and the clinician will be confident of the correct course. However, in certain populations, complications are common, and the best therapy has yet to be proven. Tailoring the evaluation and treatment to the risk of complications is imperative. With careful evaluation, individualized therapy and close follow-up, the majority of patients can be expected to do well.

Patients' understanding of the roles of interns, residents, and attending physicians in the emergency department.

OBJECTIVE: To assess patients' knowledge of the responsibilities and roles of physician training in the ED. METHODS: This was a prospective survey of a convenience sample of 345 adult patients and family members in an academic county ED. Thirty questions addressed the different roles, responsibilities, and hierarchies of physician levels of training. Four opinion-based questions assessed patients' willingness to have physicians-in-training care for them. RESULTS: 96.5% of the surveys were returned. Of the participants responding, 68% were Hispanic, 23% were non-Hispanic white, and 55% were women. Forty percent of the participants indicated that they had education greater than a high school diploma. Most participants answered fewer than 50% of the questions correctly, indicating that they did not understand the levels of physician training. Participants with higher education were more likely to know the correct answer. Seventy-nine percent of the participants believed that it is very important to know the level of training of their physicians. However, only 34% of the participants actually thought they knew the training level of their physicians when they were being treated. Twenty-nine percent of the participants did not want learning to take place on themselves by physicians-in-training. CONCLUSION: Participants believe that it is important to know their physicians' level of training, but they do not understand the roles and responsibilities of physicians-intraining in the medical training system in which they receive care. In particular, patients who have less than a high school education seem to know least about this system.

Follow-up compliance in febrile children: a comparison of two systems.

OBJECTIVES: Follow-up compliance is critical in febrile children because they may harbor unrecognized life-threatening illnesses. This study compares follow-up rates between 2 systems: Wilford Hall Medical Center (WHMC), with preset appointments after ED release, and free medical care; and Fairfax Hospital (FFX), where parents must arrange follow-up appointments after ED release, and are responsible for payment for their follow-up visits. The study also investigated factors associated with follow-up compliance. METHODS: This was a prospective, observational study of febrile children seen in 2 EDs with different systems for patient follow-up. From ED records and parental phone calls, diagnosis, follow-up compliance, and demographics were collected. Data were analyzed using logistic regression and chi2. RESULTS: 423 children met entrance criteria, and 330 parents were successfully contacted after the child's ED release (146 from WHMC; 184 from FFX). The WHMC children were more likely to comply with follow-up than were the children in the FFX system (92% vs 67% follow-up, odds ratio 2.5, 95% CI 1.1-5.3). Other factors associated with noncompliance with recommended follow-up were: Hispanic ethnicity, non-English-speaking parents, and follow-up suggested for >24 hours after ED release. For FFX, self-pay, lack of a follow-up physician, parents' dissatisfaction with the ED medical care, and diagnosis of otitis media were also significant factors found associated with noncompliance. CONCLUSION: Febrile children evaluated in a medical system with prearranged follow-up appointments and free medical care are more likely to comply with recommended follow-up than are those evaluated in a system where payment and appointments are the responsibility of the parents. Efforts should be made to improve follow-up compliance by modeling the WHMC system.

Acute visual change.

Changes in vision or loss of vision are common complaints for patients presenting to the emergency department. Such complaints may represent a simple problem related to recent trauma, early evidence of a systemic disease, or may be a vision-threatening lesion. A logical and organized approach to the history and the physical examination of the patient with eye complaints is key to the diagnosis and treatment of the more significant causes of these complaints. This article reviews an organized approach to the patient with complaint of visual loss and considers the wide differential diagnosis. It focuses specifically on the evaluation of the patient complaining of visual changes resulting from central retinal artery occlusion, central retinal vein occlusion, retinal detachment, acute angle-closure glaucoma, giant cell temporal arteritis, and retrobulbar hemorrhage.

Chemical method to increase extreme ultraviolet microchannel-plate quantum efficiency.

The quantum detection efficiency of photon-counting microchannel-plate detector channels can be increased by a factor of 2 in the extreme ultraviolet bandpass, from 256 A to 1024 A, by subjecting the input channel plate to a chemical solution treatment. The efficiency increase has proven to be insensitive to the exposure of laboratory atmosphere and is stable over the extracted charge lifetime equivalent of multiyear astrophysical observations. Chemically treated microchannel plates that are overcoated with opaque photocathodes of KBr and CsI show a factor of 2 quantum detection efficiency increase from 834 A to 1100 A in comparison with previous measurements using conventional untreated microchannel plates.

Cardiovascular radiography.

The differential diagnosis of acute chest pain and shortness of breath is extensive. A plain chest radiograph often is ordered to aid in establishing the precise diagnosis. Frequently, this useful imaging tool is viewed quickly, and thus, many important diagnostic clues can be missed. This article provides an organized approach to interpreting the chest radiograph and reviews some of the important radiographic findings of various diseases.

Acquired immunodeficiency syndrome with disseminated toxoplasmosis presenting as an acute pulmonary and gastrointestinal illness.

Encephalitis due to the protozoan Toxoplasma gondii has emerged as a common cause of central nervous system disease in patients with acquired immunodeficiency syndrome. Extraneural disease is less common and more difficult to diagnose. We report a case of widely disseminated toxoplasmosis that presented as acute gastrointestinal and pulmonary disease in a patient without a prior diagnosis of acquired immunodeficiency syndrome. The diagnosis of toxoplasmosis was made only at autopsy. Antemortem diagnosis of disseminated T gondii infection requires a high degree of clinical suspicion and the prompt utilization of appropriate diagnostic testing. Since toxoplasmosis is a potentially treatable opportunistic infection, diagnosis allows the swift institution of anti-Toxoplasma therapy.

Squamous cell carcinoma in situ arising in an ovarian mature cystic teratoma. Report of one case with histopathologic, cytogenetic, and flow cytometric DNA content analysis.

A squamous cell carcinoma in situ arose in an ovarian mature teratoma (ie, dermoid cyst) in a 62-year-old woman. Flow cytometric DNA content analysis of paraffin-embedded in situ carcinoma showed a normal DNA content with moderate to high proliferative activity (S-phase fraction estimate, 16% to 18%). Cytogenetic analysis of the in situ cancer and the benign cystic portion of the tumor revealed a 46,XX karyotype. In addition, the benign cystic portion of the tumor revealed homozygous chromosomal heteromorphisms, compared with heterozygous markers found in peripheral blood lymphocytes. These results show that this squamous cell carcinoma in situ was euploid and suggest that the mature cystic teratoma was derived from a single germ cell after meiosis I.

Clinical vampirism. A presentation of 3 cases and a re-evaluation of Haigh, the 'acid-bath murderer'.

Clinical vampirism is named after the mythical vampire, and is a recognizable, although rare, clinical entity characterized by periodic compulsive blood-drinking, affinity with the dead and uncertain identity. It is hypothetically the expression of an inherited archaic myth, the act of taking blood being a ritual that gives temporary relief. From ancient times vampirists have given substance to belief in the existence of supernatural vampires. Four vampirists, including Haigh, the 'acid-bath murderer', are described. From childhood they cut themselves, drank their own, exogenous human or animal blood to relieve a craving, dreamed of blood-shed, associated with the dead, and had a changing identity. They were intelligent, with no family mental or social pathology. Some self-cutters are auto-vampirists; females are not likely to assault others for blood, but males are potentially dangerous. Vampirism may be a cause of unpredictable repeated assault and murder, and should be looked for in violent criminals who are self-mutilators. No specific treatment is known.

Drugs, alcohol and violence in 604 male offenders referred for inpatient psychiatric assessment.

Of 604 White and Coloured male offenders in the Cape referred for inpatient psychiatric observation, 52% habitually indulged heavily in alcohol, drugs (mostly dagga (cannabis)) or both. Indulpence in alcohol alone was frequently associated with violence and sexual assaults, alcohol and drugs together less, and drugs alone least. Those who indulged in drug-taking (i.e. dagga, LSD and hard drugs) were less frequently associated with violence, rape and other sex crimes than were those who did not; 60% of sex offenders were non-abusers. Out of 101 severely psychopathic patients in the sample, only 1 who indulged in drugs but not alcohol was charged with a crime of violence or sex. There was no evidence of a potentiating action between alcohol and dagga towards violent behaviour. Dagga appeared to diminish the action of alcohol, and may inhibit urges toward violence and rape in aggressive persons and psychopaths. Drugs did not release or set off violent reactions, and drug indulgence was associated with stealing without violence. Some implications for forensic psychiatry and arguments about drug indulgence as an extenuating factor in serius crime are discussed.