Detection of occult pneumothoraces on abdominal computed tomographic scans in trauma patients.

BACKGROUND: An unrecognized, or occult, injury is particularly dangerous in trauma patients, who often have multiple life-threatening injuries. We sought to determine the frequency and quantify the utility of the abdominal computed tomographic (CT) scan in detecting occult pneumothoraces. METHODS: Charts of all trauma patients diagnosed with a pneumothorax over a 7-year period were retrospectively reviewed for findings on admission chest radiograph, abdominal CT scan, and other demographic data. RESULTS: A total of 312 charts were reviewed, with 230 patients identified as having a pneumothorax at admission. Of the 230 patients, 126 (54.8%) had an occult pneumothorax identified on abdominal CT scan. In these patients, the mean Trauma Score was 14.1 +/- 2.9 and the mean Injury Severity Score was 24.1 +/- 11.2. In the group of occult pneumothoraces, 84 (66.7%) underwent chest tube placement. CONCLUSIONS: Abdominal CT scanning provided important information about thoracic trauma often missed on initial evaluation in the trauma bay. This information frequently affected the patient's clinical management.

MTHFR (C677T) polymorphisms and stage III colon cancer: response to therapy.

BACKGROUND: Leucovorin and 5-fluorouracil (5-FU) chemotherapeutics are often used as coinhibitors of the thymidylate synthase pathway to thwart the growth of cancer cells in certain types of neoplasms. The metabolism of leucovorin is mediated through the enzyme methylenetetrahydrofolate reductase (MTHFR). A common polymorphism in the MTHFR gene has been reported to be responsible for as much as a 70% reduction in activity of this enzyme when present in the homozygous form. METHODS AND RESULTS: A total of 51 stage III colon cancer patients were identified through our tumor registry. Non-neoplastic, archived tissue was obtained for each patient and subjected to MTHFR C677T PCR-RFLP genotyping. The MTHFR C677T allele was present in 32 patients (28 heterozygotes and 4 homozygotes). The remaining 19 patients carried only the wild-type allele. Overall survival was 42.10% (8/19) for wild types and 43.757% (14/32) for those with at least one C677T allele. Of the four homozygotes identified, three have succumbed to their cancer and one is alive with cancer. CONCLUSIONS: We were unable to demonstrate a survival difference between those stage III colon cancer patients receiving leucovorin therapy that carried the MTHFR C677T allele and those that were wild type for this allele. The results of this study suggest that certain subgroups (ie, homozygotes) of patients may benefit from genotypic analysis of the MTHFR gene.

Simultaneous polymerase chain reaction restriction fragment length polymorphism identification of the factor V Leiden allele and the prothrombin 20210A mutation.

A novel mutation in the 3' untranslated region of the prothrombin gene, prothrombin 20210A, recently has been identified. This mutation is associated with increased serum prothrombin levels and an increased risk for venous thromboembolism. Patients who carry a mutation in the factor V gene (factor V Leiden) have also been demonstrated to be at increased risk for venous thromboembolism, and previous studies have identified a population prevalence of approximately 5% to 10% for the factor V Leiden allele. To simply and reliably identify patients who carry both genetic defects, a novel assay was developed that simultaneously determines the genotype of patients for the factor V Leiden allele and the prothrombin 20210A mutation. Representative samples (samples positive and negative for each mutation and a "double mutant") were then subjected to this single-tube genotyping assay. The results indicate that the simultaneous genotyping of these mutations will readily characterize the allelic status of patients for the two most frequent genetic mutations in the coagulation cascade.

The role of preoperative factor V Leiden screening in different geographic populations.

Patients harboring a specific mutation in the coagulation factor V gene have been identified as being at significantly increased risk for venous thrombosis. A simple genetic test that identifies carriers of this mutation (the factor V Leiden allele) is available and may have utility in various clinical settings, including preoperative risk assessment for thromboembolic complications. In this regard, it is generally agreed that prospective studies addressing the role of preoperative factor V Leiden mutational analysis are needed to clearly define the clinical prognostic/diagnostic significance of the presence of this mutation in surgical patients. This report questions the role that population dynamics (genetic and environmental backgrounds of individual populations) plays in the analysis of factor V genotypic data in relation to postsurgical thromboembolic complications. We have determined that the frequency of individuals carrying the factor V Leiden allele is 7.9 per cent for our South Central Pennsylvania population (395 wild type, 32 heterozygotes, 2 homozygotes) using a polymerase chain reaction-restriction fragment length polymorphism technique that specifically detects the factor V Leiden mutation. This baseline population information is useful from both a clinical and a basic science viewpoint. However, considering the various unknown genetic and environmental differences between geographically distinct populations, the significance of this result, in terms of clinical management of our surgical patients, is yet to be determined.

Detecting and treating bulimia nervosa: how involved are family physicians?

BACKGROUND: Relatively little is known about bulimia nervosa in the primary care setting. Existing medical literature suggests that primary care physicians have limited experience with bulimia nervosa. METHODS: Experiences of family physicians with bulimia nervosa specifically and eating disorders in general were assessed by a questionnaire mailed to a representative sample (596 subjects) of Ohio family physicians. The response rate was 52.6 percent. RESULTS: Approximately 30 percent of the respondents had never diagnosed bulimia in a patient; 60 percent had no bulimic patients at the time of the survey. The mean career total of bulimic patients per physician was 5.3 (SD = 5.6). Younger physicians and female physicians were more likely to have bulimic patients. Having bulimic patients correlated significantly with having contact with bulimic and with anorexic persons in nonoffice settings. CONCLUSIONS: Despite a general prevalence rate of about 1 percent for bulimia (much greater for the female population, particularly in adolescents and athletes), nearly one third of Ohio family physicians have never diagnosed bulimia in a patient, and nearly two thirds are not currently providing care for bulimic patients. Because screening is quick, inexpensive, and straightforward, all at-risk patients--athletes or those who have concerns related to paucity of menstruation, gastrointestinal symptoms, dieting or weight concerns, and depression--should be screened for bulimia.

Use of the neutrophil:lymphocyte ratio in the diagnosis of appendicitis.

In patients with right lower quadrant pain, the total white cell count is an unreliable predictor of appendicitis. It has been reported that the lymphocyte count can fall in acute appendicitis. This study was undertaken to investigate whether the neutrophil:lymphocyte ratio is a more sensitive indicator than the total leucocyte count. A retrospective study was performed of patients undergoing appendectomy for suspected appendicitis over a 2-year period. A total of 402 patients were identified; histopathology confirmed appendicitis in 367 (91%). Other significant pathology was found in 13 (3.2%). Twenty-two (5.5%) had a histologically normal appendix and recovered uneventfully with no other diagnosis being made. A total of 298 (79%) patients with appendicitis had an elevated preoperative total white cell count. The neutrophil:lymphocyte ratio was calculated for each patient. Using an upper limit of 3.5:1, it was found that 324 (88%) of patients with appendicitis had a ratio equal to or greater than this value. This was significantly different from the proportion with a raised total leucocyte count (P = 0.001). We suggest that the simple calculation of the neutrophil:lymphocyte ratio may provide a parameter that is more sensitive than the total leucocyte count in the prediction of appendicitis.

Warthin's tumor. A high incidence and no sex predominance in central Pennsylvania.

Papillary cystadenolymphoma, or Warthin's tumor, is a monomorphic adenoma found in salivary glands. It nearly always occurs in the parotid gland, and is reported to occur in 5% to 14% of all parotid tumors according to most studies. The tumor has a universally accepted male predominance, with an increasing incidence in females having been reported over the last four decades. A review of all primary parotid gland tumors seen at York (Pa) Hospital for the last 10 years was performed. Warthin's tumor was diagnosed histologically in 42 (30%) of 138 primary parotid gland tumors, with no significant sex predominance identified (22 men, 20 women). A significantly higher percentage of all parotid gland tumors, and especially Warthin's tumor, was associated with smoking in both males and females.

Repair of a traumatic noncircumferential hepatic bile duct defect using a vein patch: case report.

Injury to the bile ducts secondary to blunt trauma is a rare but potentially fatal condition that presents a difficult diagnostic and treatment challenge. Various treatment options exist for repair. Vein patch repairs have been criticized because of reports of subsequent fibrosis and stricture formation. This case report describes the successful repair of a traumatic, noncircumferential defect of a hepatic bile duct with a vein patch, and stresses the importance of an adequate duration of stenting.

Key issues in nutrition. Disease prevention through adulthood and old age.

Certain dietary practices are valid methods of lowering the risk of disease. Others, while popular, have unproven benefits or may even be associated with risks of their own. Careful evaluation of hypercholesterolemia is necessary. Persons with a high level of low-density lipoprotein (LDL) cholesterol and a low level of high-density lipoprotein (HDL) cholesterol need diet therapy, because they are at increased risk of cardiovascular disease. Weight reduction and fat restriction can lower blood pressure, help control hyperglycemia, and improve the LDL cholesterol-HDL cholesterol ratio. Some evidence indicates a protective role of beta carotene against cancer in animals. However, hypervitaminosis A is dangerous and relatively easy to accomplish, so supplementation beyond a multivitamin tablet is discouraged. Data about inhibition of cancer in humans through use of high doses of vitamin E or C or selenium are inconclusive, and studies of effects of long-term ingestion are not available. In general, megadoses of even healthy substances are thought to be dangerous. Decreased consumption of fat, increased consumption of foods high in fiber, and elimination of alcohol and tobacco are sensible recommendations. Consumption of cruciferous vegetables has not been proven to reduce the incidence of cancer, but a moderate amount of them in the diet would seem reasonable.

Key issues in nutrition. Supplementation through adulthood and old age.

A varied and balanced diet is usually adequate to meet the energy, protein, vitamin, and mineral requirements of adults and the elderly. However, some high-risk groups may require supplementation or special dietary recommendations. Some examples are persons on a weight-loss diet, alcoholics, premenopausal women, women taking oral contraceptives, postmenopausal women not taking estrogen, and patients with diminished immunity or cancer. An understanding of the nutritional needs of adult and elderly patients is vital if the primary care physician is to answer their questions and help them maintain good health through dietary adjustment or supplementation.

Key issues in nutrition. During childhood and adolescence.

Good nutrition is important between ages 2 and 18, because growth and maturation are taking place and because future eating habits are being established. The primary care physician can assist children and adolescents by evaluating high-risk factors, such as a family history of cardiovascular disease or hypercholesterolemia, and by recommending supplemental nutrients as indicated. Possibly more important, though, is the counseling the physician can give these patients and their parents to promote a life-style that may prevent disease.

Key issues in nutrition. From conception through infancy.

Pregnant and lactating women and infants are at nutritional risk because of their special needs; both require adequate dietary nutrition and, often, dietary supplementation. For example, the mother's increased requirements for iron, calcium, folic acid, and vitamin D usually must be met with increased milk intake and multivitamin-with-mineral supplements. Since the pregnant and the lactating woman can pass both nutrients and nonnutrients to the child, she should be advised on a well-balanced, high-quality diet that is free of drugs or other additives that may be harmful. Although either breastfeeding or the use of formula may fulfill energy and protein needs, the infant may require supplemental vitamins K and C, fluoride, and iron.

Gonococcal dermatitis-arthritis syndrome.

Gonococcal dermatitis-arthritis syndrome should be a diagnostic consideration in an adolescent or a young adult presenting with a skin rash in association with joint pain and swelling. Cultures and/or gram-stained smears should be obtained. Patients usually respond rapidly to antibiotic therapy.

Comparative symptomatology of phobic and nonphobic panic attacks.

Following a survey of the general population, the prevalence of panic symptomatology was compared in 12 phobic and 46 non-phobic subjects identified from the sample. Fear of losing control (p = .019) was more characteristic of phobic panic attacks while dyspnea (p less than or equal to .05) and dizziness (p less than or equal to .02) were more prevalent in nonphobic attacks. Within this population, it appears that there are few large differences in symptom frequency between the two groups. However, the differences that do exist may be due to either a difference in pathophysiology or may reflect development of secondary hyperventilation in those with nonphobic attacks.

Occupational stress, personal strain, and coping among residents and faculty members.

Differences in ratings by 155 individuals at four levels of medical experience (faculty members and first-, second-, and third-year residents) on measures of occupational stress, personal strain, and availability of coping resources were examined. Multivariate and univariate analyses of data indicated significant differences in the measures among the experience levels. Measures of the availability of coping resources reflected the major source of differences, with the first-year residents reporting significantly fewer overall coping resources than faculty members. No significant differences were detected among the four groups on overall measures of occupational stress and personal strain. There were differences between first-year residents and faculty members on the subscales measuring physical environment stress, physical strain, recreation, and self-care. The findings suggest that residency education interferes with first-year residents' abilities to cope and places their physical well-being at risk. The findings support the need for residents to employ coping strategies during the residency years and provide empirical guidance regarding the kind of coping strategies needed.