Consultation etiquette: a proposed set of guidelines.

Too often, actions and decisions affecting patient care are determined by expediency, cost-effectiveness, and time constraints. At risk of sacrifice are ethics and professionalism, pillars essential to the very structure of medical practice. In particular, there appears to be an erosion of consultation etiquette-exchanges between physicians and patients as well as among physicians. While methods to maximize efficiency are essential to medical practice, they should not come at the expense of etiquette. To improve patient care and strengthen relationships between patients and physicians, as well as relationships between referring and consulting physicians, a set of guidelines for improving consultation etiquette is proposed.

Inflammatory bowel disease in women: impact on relationship and sexual health.

Inflammatory bowel disease (IBD) has an impact on the quality of life of women regarding partner relationships and sexual health. Partner relationship and sexual health in women with IBD has been targeted minimally for investigation in the literature devoted to psychological, relationship, and sexual functioning. The purpose of the present article is to describe the concerns of women with IBD, specifically evaluating individual concerns, partner relationships, and sexual functioning after surgery and to elucidate some of the difficulties in identifying such problems. Gynecologic issues and pregnancy concerns are described. Actual case studies are presented that reveal many of the difficulties women with IBD encounter in their relationships as a consequence of disease activity and treatment interventions. Additional research evaluating relationship difficulties, sexual comfort, and sexual behaviors as a consequence of disease activity is required to understand further and improve the quality of life and well-being of these women.

Achalasia: a review of therapeutic options and outcomes.

Advances in achalasia has led to the development of new therapeutic options. This review will focus on methodology and outcomes of two established techniques; pneumatic dilation and surgical myotomy; and one new technique, LES injection of botulinum A toxin.

Intestinal strongyloidiasis: recognition, management, and determinants of outcome.

Significant advances have occurred in our understanding of the biology, immunology, and immunopathology of the usually asymptomatic human infection by the intestinal parasite, Strongyloides stercoralis. Factors that increase the risk for the occurrence of symptomatic intestinal hyperinfection and/or often-fatal disseminated strongyloidiasis have been better defined. The pathophysiology underlying these risk factors, whether disease-related or iatrogenically induced, is a compromised immune system leading to dysfunction of TH-2 helper cells. These specialized lymphocytes are central to maintaining the delicate balance that exists between the infected human host and the stabilized parasite. Recognition of risk factors that impair the function of TH-2 lymphocytes is essential to heightening the index of clinical suspicion enhancing earlier, accurate diagnosis, and the introduction of appropriate therapy. This review summarizes what is understood about infection by S. stercoralis; its focus will be on the epidemiology, diagnosis, clinical presentation patterns in the immunocompetent and immunocompromised human hosts, and recommended treatment regimens.

Small Bowel Ischemia.

Small bowel ischemia is a relatively uncommon disorder requiring prompt recognition and aggressive management if significant morbidity and mortality are to be averted. The pathophysiology of the ischemic event usually will determine the management approach used. Factors to be considered include whether the ischemia is the consequence of arterial or venous occlusive disease; the cause and nature of the ischemia (ie, a consequence of arterial spasm, inflammation, complete or incomplete occlusion); whether the occlusion is the result of an embolus or thrombosis; the preexistence and degree of development of arterial collateral channels; and the existence and extent of comorbid conditions. Established and experimental therapeutic interventions have varied in efficacy and include 1) correction of physiologic alterations predisposing to the ischemic event, 2) angiography with arterial infusion of vasodilators; 3) embolectomy or thrombectomy, and resection of necrotic bowel; 4) anticoagulation (veno-occlusive disease); and 5) selective application of thrombolytic agents. The overall success of any therapeutic intervention depends upon the early recognition and management of ischemia, as the incidence of morbidity and mortality rises after infarction occurs.

Gastroenterology.

Rectal bleeding with signs of peritoneal irritation raises many differential diagnostic possibilities. In this setting, the order in which various tests are performed in an effort to find the source of bleeding can be as important as which diagnostic procedures are elected.

Treatment of achalasia with botulinum A toxin.

Achalasia is an idiopathic neuromuscular disorder of the esophagus which is associated with absence of esophageal peristalsis and incomplete relaxation of a normal or raised lower esophageal sphincter (LES). Dysphagia is the most commonly associated symptom. Conventional therapeutic approaches are directed to reducing LES pressure and include orally-administered smooth muscle relaxants, forceful sphincter dilation with balloon dilators, and open or laparoscopic-assisted myotomy of the LES. Pharmacologic therapies have a low success rate. Forceful dilation has a perforation complication rate of 2% to 5%, and myotomies may precipitate significant gastroesophageal reflux, a complication minimized when a partial fundal wrap is employed simultaneously. In recent years, botulinum toxin, utilized widely as a striated muscle relaxant in managing blepharospasm, anal sphincter spasm, and muscle spasm complicating CVAs, and in smoothening facial wrinkles, has been extended to the management of achalasia on the basis that it impairs smooth muscle responsiveness to acetylcholine. Eighty units of Botox (botulinum toxin) are injected directly into the endoscopically (endoscopic ultrasound techniques may facilitate localization) located LES region (20 units into each of 4 quadrants). Symptom relief lasting 6 months on average is experienced in more than 65% of treated patients, and the complication rate is negligible. This therapeutic option is reserved for patients too ill to undergo any surgical procedure and is most effective when the lower esophageal region is hypertonic.