Equity in health: the importance of different health streams.

This paper develops a conceptual framework in which preferences about the distribution of future health gains depend on differences in four 'health streams'. These are as follows: (1) the amount of health to be gained; (2) the no-treatment profiles; (3) the amount of health experienced thus far: and (4) the amount of health gained previously as a result of public health interventions. This classification puts the well-established concerns for severity (stream 2) and age weights (stream 3) into a more complete analytical framework. Stream 4 has not been discussed to date and the paper suggests some moral arguments about the distributive relevance of this stream of health.

Toxic epidermal necrolysis.

Toxic epidermal necrolysis (TEN) is a life-threatening condition in which the epidermis blisters and peels in large sheets. The clinical syndrome and diagnosis are reviewed. Current treatment and prevention of complications are discussed. The key to low morbidity and mortality in TEN is early intervention. Physicians should be knowledgeable about TEN and the appearance of the skin in its initial presentation.

Blunt chest trauma and suspected aortic rupture: reliability of chest radiograph findings.

The chest radiographs of 86 patients with suspected aortic rupture from blunt chest trauma were reviewed. Seventy-three patients had no evidence of aortic rupture on aortography or surgical exploration, and 13 patients had surgically confirmed rupture. Sixteen radiographic findings were analyzed for sensitivity and specificity in detecting aortic rupture. The following findings were not statistically significant: hemothorax on either side; rib fractures on either side; pneumothorax on either side; lung contusion; widened left paravertebral stripe; and widening of the mediastinum, along with an increased ratio of mediastinal width to chest width. The most helpful findings leading to suspicion of aortic rupture included nasogastric tube or tracheal deviation to the right at the T4 level; depression of the left mainstem bronchus; and loss of the aortic contour or knob and left apical cap. False positives and false negatives occurred with each radiographic sign, indicating that there is no single finding that is absolutely reliable in predicting or excluding significant injury in every patient with suspected aortic rupture. Analysis of combinations of findings found that when the aortic contour and knob are normal and the nasogastric tube and trachea are not deviated, there was no case of aortic rupture in four consecutive years of experience. These four signs can be used to exclude aortic rupture.

Meckel diverticulum: radiologic demonstration by enteroclysis.

Thirteen patients with surgically confirmed Meckel diverticula encountered in a 30 month period are reported. Of 11 symptomatic patients, all had lower gastrointestinal bleeding, except one who had recurrent abdominal pain only. Two diverticula were incidental, coexisting with Crohn disease of the distal ileum. One of these had occasional diarrhea and hematochezia. The diagnosis was established preoperatively by enteroclysis in 11 of these cases. The enterographic demonstration of the mucosal triangular plateau or the triradiate fold pattern indicating the site of exit of the omphalomesenteric duct should lead to a diagnosis of Meckel diverticulum. Pitfalls in interpretation due to the pseudotriangular plateau appearance formed by superimposition of two intestinal loops and the pseudosaccule produced by the axial projection of a fixed loop of bowel and the differential diagnosis are discussed. Enteroclysis seems to be the most dependable method currently available for preoperative demonstration of Meckel diverticulum.

Management of persimmon bezoars (diospyrobezoars).

Since 1946, 20 men and one woman aged 40 to 76 years (average 57) were operated upon for complications of diospyrobezoars. Shortly after eating persimmons, 11 (52.4%) had severe abdominal cramping, anusea, vomiting, and pyrexia. Twelve of 17 (70.9%) with gastric bezoars had hematemesis or melena caused by an associated gastric ulcer, while five (29.1%) had only moderate dyspepsia. In four (19.1%), the bezoar had lodged in the ileum, causing obstruction. Enzymatic therapy is indicated in those with minor symptoms. Gastrotomy or gastrotomy with bezoar removal and wedge resection of the gastric ulcer is recommended when enzymatic therapy fails, or when there is gastric outlet obstruction or marrise hemorrhage. Emergency exploration with removal is necessary when the persimmon bezoar causes ileal obstruction.