Completing the circle: follow-up screening of STD patients in three clinics of the United States Indian Health Service.

We reviewed charts of newly diagnosed STD patients in three health facilities to determine the proportion who received follow-up STD screening. In a 12-month period, the three facilities had 140 STD cases. STD screening was not indicated for 50 (36%) patients. Among the 90 remaining STD patients, 29 (32%) were screened and 61 (68%) not screened. Among non-screened patients, 36% (22/61) were tested, but outside the time parameters allowed by the audit. The remaining 64% (39/61) received no screening at all, and represented clinical missed opportunities; in this group, nearly all (95%) had chlamydia but were not screened for HIV or syphilis. Linking chlamydia patients with a screen for HIV and syphilis using a clinical reminder in the facilities' electronic health record (EHR) or other tool, would eliminate 95% of the missed opportunities in this sample.

Severe complications during the management of a child with late presentation of a diaphragmatic hernia.

We report on a 3-year-old boy with late presentation of congenital diaphragmatic hernia who developed cardiac arrest after induction of anaesthesia. The paper discusses the anaesthetic technique, in particular ventilation during and after induction, how these techniques contributed to the complication, and how they might have been avoided.

PRIME-MD: its utility in detecting mental disorders in American Indians.

OBJECTIVE: To examine the utility of using PRIME-MD (Primary Care Evaluation of Mental Disorders) for diagnosing mental disorders in American Indians. METHOD: One hundred randomly selected, adult, American-Indian patients who receive health care services at an urban Indian Health Service primary care clinic were evaluated for mental disorder by three primary care physicians using the PRIME-MD diagnostic assessment procedure. The main outcome measures were PRIME-MD diagnoses, diagnoses by an independent mental health professional, and treatment/referral decisions. RESULTS: Eighteen percent of the patients had a threshold (met full DSM-IV criteria ) PRIME-MD diagnosis, and an additional 17 percent had a subthreshold PRIME-MD diagnosis. The most frequently occurring PRIME-MD diagnoses were: probable alcohol abuse/dependence, major depressive disorder, and generalized anxiety disorder. Over 60 percent of the patients with a PRIME-MD diagnosis who were known "somewhat" or "fairly well" to their physician had not been recognized as having that psychiatric disorder prior to the PRIME-MD assessment. Therapy and/or referral was initiated for nineteen of the twenty-seven patients with a PRIME-MD diagnosis who were not previously receiving treatment. The primary care physicians were able to complete the PRIME-MD evaluations within an average of 7.8 minutes. There was a fair agreement between the PRIME-MD diagnoses and the diagnoses of the mental health professional (kappa = 0.56; overall accuracy rate = 79%). CONCLUSIONS: The present study represents the first formal examination of the use of PRIME-MD with American Indians. The results are encouraging. Further studies using PRIME-MD with other urban groups and reservation populations are recommended.

[Surgical treatment of necrotizing fasciitis]. / Kirurgisk behandling ved nekrotiserende fasciitis.

We present nine patients with necrotizing fasciitis. Two of them had Fourniers gangrene. Predisposing factors included diabetes mellitus, alcohol and drug abuse. Local signs were redness, swelling and pain rapidly followed by fever and deterioration in the patient's general condition. Soft tissue-gas was observed in all patients. It was found either clinically, on roentgenograms or by CT. Bacteria were found in blood cultures and/or necrotic tissues in all patients. The dominating treatment was radical surgical excision and early reexplorations. Antibiotics, intensive care support and early parenteral nutrition were given. Four patients were given hyperbaric oxygen treatment. The overall mortality rate was 11%. Amputation of one lower extremity became necessary in three patients. In these cases 4-8 days had elapsed between the onset and the first surgical excision. We find it important to underline early diagnosis and radical surgical excision in patients with necrotizing fasciitis.

Granulocytes in bronchial lavage fluid after major vascular surgery.

Increased numbers of polymorphonuclear granulocytes (PMN) in the airways, as measured by PMN content in bronchial lavage fluid (P less than 0.01), were found 3 h postoperatively in ten patients undergoing surgery for lumbar aortic aneurysms. An increase in plasma levels of the complement split product C3dg from 6 (0-19) AU/ml preoperatively to 20 (13-50) AU/ml 3 h after surgery (P less than 0.01), indicates an activation of the complement cascade. These changes were not accompanied by increased elastase activity in the bronchial lavage fluid or by major changes in pulmonary blood gas exchange or vascular resistance, indicating that massive PMN activation, analogous to that proposed in adult respiratory distress syndrome (ARDS) had not taken place. In conclusion, complement system activation and migration of PMN into the airways, as seen in connection with major vascular surgery, does not seem to contribute to ARDS-type pulmonary dysfunction.

White blood cell populations in patients undergoing major vascular surgery.

In 16 patients undergoing major vascular surgery, study was made of variations in white blood cell populations, cortisol concentration, pulmonary vascular resistance and intrapulmonary shunting. Six hours post-operatively the number of circulating lymphocytes and the relative proportion of T-lymphocytes were significantly reduced. During and after operation the relative proportion of T-suppressor cells rose from 20.5 to 44.8% of all lymphocytes. There was corresponding fall in T-helper cells. The proportion of lymphocytes with surface-bound Ig (B-lymphocytes) did not alter during surgery. No correlation was found between the number of circulating white blood cells and the haemodynamic parameters. Intrapulmonary shunting, which was increased already before operation, remained unchanged during and after surgery. Cortisol levels increased significantly and peaked 6 hours postoperatively. Significant correlations were found between cortisol levels and reduction in total number of lymphocytes and in percentage of T-lymphocytes. The study thus demonstrated significant changes in white blood cell populations following major vascular surgery and indicated a correlation between lymphocyte concentration and cortisol level.