Pustular vasculitis of the hands.

A case of pustular vasculitis of the hands with evidence of systemic involvement is described. A 64-year-old woman presented with a 2-day history of large, tense bullae arranged symmetrically over the dorsum of the three radial digits and extending on to the radial aspect of the dorsum of each hand. The bullae caused some discomfort and prevented normal use of her hands. There was no response to antibiotic therapy initiated prior to referral to hospital. Initial investigations revealed a raised white cell count with a neutrophilia, a raised erythrocyte sedimentation rate and a raised C-reactive protein. Abnormalities of liver function were detected. Aspirates from the bullae and blood cultures were sterile. The histology of debrided tissue demonstrated a florid neutrophilic dermal infiltrate with many blood vessels associated with prominent fibrin. A diagnosis of pustular vasculitis of the hands was made. The bullae were surgically debrided and treatment with oral corticosteroids was started. Two days after commencement of oral prednisolone, a crusted pustule appeared on her upper cutaneous lip. There was rapid resolution of both the vasculitis of the hands and the pustule on her upper lip following an increase in the dose of oral prednisolone. The patient was discharged on the seventeenth day following admission.

Granulomatous glomerulonephritis in intravenous drug users: a report of three cases in oxycodone addicts.

Various well-documented renal lesions are associated with intravenous drug use; however, intraglomerular mesangial granulomas have not been previously described. We report three patients who developed an unusual granulomatous glomerulonephritis and interstitial nephritis after intravenous injection of oxycodone, derived from suppositories. Granulomas were seen in an intraglomerular mesangial and also interstitial location. In both sites, the granulomas were associated with filamentous material, presumably derived from a component of the suppositories. This material was periodic acid-Schiff-positive, but negative with Congo red and silver stains. Ultrastructurally, the filamentous material was seen within the mesangial granulomas and also in a subendothelial location, suggesting derivation from the circulation with subsequent transport across the basement membrane and accumulation in the mesangium, where a granulomatous reaction was elicited. All patients developed a degree of renal failure; two of the patients require hemodialysis 20 and 30 months after presentation.

Assessing children's development using parents' reports. The Child Development Inventory.

The Child Development Inventory (CDI), completed by parents at home, assesses the development of social, self-help, motor, language, letter and number skills, and presence of symptoms and behavior problems of children between the ages of 15 months and 5 years. The results provide the pediatrician with a profile of the child's development, problems, and strengths, and are an aid to comprehensive assessment. CDI norms and validity were determined for a community sample of 568 children. The CDI developmental scales correlate closely with age (r = 0.84). CDI results identified all the normative group children who were enrolled in early childhood/special education (N = 26) and correlated with academic achievement for children in kindergarten (N = 132). CDI scales correlated with reading achievement in kindergarten as follows: general development 0.69, letters 0.56, language comprehensive 0.42, expressive language 0.36, and self-help 0.35. Thus, the CDI provides a useful measure of children's development and, because of its reliance on parental reports, offers an effective approach to developmental assessment in the busy pediatric practice.

Gastrointestinal bleeding from hepatocellular carcinoma invading the stomach.

Bleeding from hepatocellular carcinoma (HCC) invading the gastrointestinal tract is very uncommon. We report the case of a 61 year old man who had a large bleed from HCC invading the fundus of the stomach. Diagnosis was eventually made at laparotomy and he is still alive 7 months after local resection.

Personal stress inventory in the screening and evaluation of family practice patients.

This study of family practice center patients assessed the broad range of their stresses and concerns, their emotional status, and personal adjustment. Two hundred and fourteen patients completed the 69-item Personal Stress Inventory (PSI) questionnaire. PSI results were related to patients' medical diagnoses classified as 1) psychological symptoms, 2) possible psychosomatic problems, 3) physical illness, or 4) well-care. For the total group, PSI concerns about financial matters, energy level, and health of other family members were as great as personal health concerns. About 15% of these patients were seriously concerned about their marriages, sexual problems or personal habits (eating, drinking, smoking, rest, exercise). Moderately high levels of stress and anxiety were reported. Patients with psychological symptoms showed the highest levels of stress, anxiety, depression, anger, and confusion and the lowest levels of emotional support and coping skills. Psychosomatic patients reported more depression, anger, and confusion and less emotional support than their physically ill counterparts.

Self-ratings of graduating family practice residents' psychological medicine abilities.

This study evaluated the psychological medicine abilities of graduating residents in the Department of Family Practice and Community Health at the University of Minnesota Health Sciences Center (n = 41). Residents were asked to complete the Psychological Medicine Inventory, a series of nine-point rating scales, which measure level of interest in the psychological aspects of patient care, degree of confidence in dealing with the psychological problems of patients, and various psychological abilities. Behavioral science faculty members familiar with the residents also rated 20 of the residents' overall level of interest and ability in psychological medicine. Residents rated themselves highest on doctor-patient relationships and on recognizing patients in distress, and lowest on psychological interviewing and the ability to be psychologically therapeutic. Item intercorrelations and factor analysis suggested that two main dimensions were being evaluated: clinical psychological abilities (including interviewing, diagnosis, consultation, treatment decisions, and treatment) and psychological sensitivity (including doctor-patient relationships, awareness of patient's reactions, and awareness of own feelings.) Residents' self-ratings correlated positively with faculty ratings.

The effect of malaria infection on primaquine elimination in the isolated perfused rat liver.

Most antimalarial drugs are eliminated by hepatic metabolism. However, the influence of malaria infection on the hepatic elimination of these drugs has not been examined. In the present study the elimination of the antimalarial primaquine has been examined in isolated perfused rat livers (IPRL) of malaria-infected Sprague-Dawley rats (90-110 g) (MI group; N = 6) and age- and weight-matched healthy rats (control group; N = 7). IPRL preparations for the MI group were established 12-15 days after rats were infected with merozoites of Plasmodium berghei (150 X 10(6) parasites/ml; 0.2 ml i.p.). At the time of study there was marked variation in the degree of parasitaemia achieved in the rats used in the MI group, from 2 to 27% of erythrocytes being infected. Livers were isolated using standard techniques and perfused at 10 ml/min in a 100 ml recycling system for 4 hr. In the control group, the perfusate disappearance of primaquine was biphasic with a mean t1/2 beta of 0.77 +/- 0.10 hr. This was prolonged in the MI group (mean t1/2 beta = 1.06 +/- 0.09 hr; P less than 0.05). There was no significant difference in the volumes of distribution of primaquine between the MI group (mean = 320 +/- 73 ml) and the control group (mean = 284 +/- 79 ml). Although there was a trend to lowered primaquine clearance in the MI group (mean 217 +/- 26 ml/hr), it was not significantly different from that seen in the control group (mean = 277 +/- 42 ml/hr; 0.10 less than P greater than 0.05). However, there was an inverse linear correlation between primaquine clearance and the percentage parasitaemia (r = 0.722, P less than 0.05). These results suggest that the extent to which primaquine elimination had been compromised was related to the severity of malaria infection, and that in severe infections reduced efficiency of elimination raises the possibility of drug toxicity.

Teaching behavioral medicine by consultation in the family practice center.

The broad goal of the behavioral medicine rotation described here is to help residents become more effective in recognizing, evaluating, and dealing with psychological problems and issues. The preceptor, a clinical psychologist, works with one resident at a time, sees all or most of the resident's patients with the resident, and consults with him or her regarding patient care and related issues. The preceptor is guided by three considerations: (1) the rotation goals and objectives, (2) the resident's expressed learning goals, and (3) the patient's problems and needs. At the beginning of the rotation, the preceptor interviews the resident regarding background and interests in medicine, family practice, and behavioral medicine and then asks the resident to complete a self-evaluation form on interest and skills in behavioral medicine. At the end of the rotation the resident again completes the self-evaluation form. Changes in self-ratings during the rotation indicate that most residents report increased confidence and ability to deal with patients' psychological problems.

Chronic lymphatic leukemia developing in a patient with multiple myeloma: immunologic demonstration of a clonally distinct second malignancy.

A patient with multiple myeloma who subsequently developed chronic lymphocytic leukemia is reported. Initial studies demonstrated clinical and hematological features of multiple myeloma with an IgM lambda paraprotein. Skeletal disease was a significant presenting feature, although relapse occurred in extraosseous sites, particularly the pleura. He developed chronic lymphatic leukemia 31 months later and immunological studies showed the malignant lymphocytes to have kappa (Kappa) light chain surface immunoglobulin, demonstrating separate clonal origin of this patient's two B-cell malignancies.

Multiple cranial nerve palsies as the presenting feature of meningeal myelomatosis.

The case of a 69-year-old man with IgGK myeloma in whom meningeal myelomatosis with multiple cranial nerve palsies developed, is reported. Review of previously reported cases of clinically apparent meningeal myelomatosis indicates this rare complication frequently presents with cranial nerve palsies; currently available treatment is ineffective.

Plasma disappearance of intravenously injected radiolabelled glycocholic acid in patients with liver disease.

The plasma disappearance of an intravenously injected tracer dose of glycocholic acid (glycine-1-14C) was compared in patients with and without diffuse hepatocellular disease. No difference was found between the two groups of patients. We conclude that this test is not a sensitive index of the presence of significant liver disease.

Giardiasis following gastric surgery.

A patient is presented who developed acute life-threatening diarrhoea due to infestation with Giardia lamblia. We propose that the severity of the illness may have been related to hypochlorhydria following gastric surgery.

The Adlerian approach: a practical psychology for family practice.

A systematic approach to understanding the patient's personality and helping him cope with common life problems is found in Adlerian Psychology. It is uniquely appropriate to family practice because it stresses the interpersonal purposes of behavior and symptoms and the influence of family constellation on the development of the individual life-style. By obtaining a small amount of data about the patient's present life situation and his family of origin, the physician can gain a basis for understanding how the patient developed his unique way of acting and reacting to the physical and social stresses of life. Interpretation of two or three early recollections reveals what the patient expects of himself, others, and life. The insight thus gained is used as the basis for a holistic assessment of the problem; a directive, supportive, action-oriented plan for treatment; and an ongoing doctor-patient relationship of mutual respect.