Myocardial infarction after diet-induced warfarin resistance.

A 35-year-old woman was receiving warfarin sodium therapy for a prosthetic aortic valve. She sustained a myocardial infarction five weeks after beginning a diet of lettuce, broccoli, and turnip greens to lose weight. Excess dietary vitamin K can cause life-threatening consequences in patients on warfarin treatment.

Axillary and subclavian venous thrombosis. Prognosis and treatment.

To clarify the prognosis of axillary and subclavian deep venous thrombosis and to determine which clinical factors influence its sequelae, we systematically reviewed the English-language literature published on this subject since 1950. Seventy-one case reports and 17 case series describing a total of 329 patients met our inclusion criteria for detailed review. There were major deficiencies in the quality, as well as quantity, of the available clinical data: few patients were enrolled at axillary and subclavian deep venous thrombosis inception, and outcome assessments were susceptible to bias and based on insensitive diagnostic tests. Posttreatment symptoms were reported in 34% of cases, pulmonary embolism in 9.4% (one half documented by lung scan or angiography), and death in 1.2% (three of four deaths due to pulmonary emboli). These complications occurred regardless of etiologic category (spontaneous, catheter related, or miscellaneous). Thrombolytic agents and surgery, in addition to anticoagulation, were often used to treat axillary and subclavian deep venous thrombosis, but there were no controlled trials to support any one approach. Until such trials are performed, therapy should be based on the anticoagulation regimens proved to be effective for deep venous thrombosis of the lower extremity. In selected patients, thrombolytic therapy and surgery may have important roles.

Prolonged effect of inhaled glycopyrrolate in asthma.

Glycopyrrolate, a quaternary ammonium anticholinergic compound is a potentially useful bronchodilator. To determine the efficacy, optimal dose, and duration of action of inhaled glycopyrrolate, we gave the drug to 11 asthmatic patients. Each subject received placebo or glycopyrrolate (100, 200, 600, or 1,200 micrograms) by inhalation in a double-blind, randomized, crossover design. Measurements included FEV1, FVC, heart rate, and blood pressure before administration of the drug and periodically for 12 hours. For eight hours following all doses of glycopyrrolate, both FEV1 and FVC (both as percent of predicted) were significantly greater for drug than for placebo. Glycopyrrolate may be a useful long-acting drug for the treatment of asthma.

'Nerves': folk idiom for anxiety and depression?

This study suggests that 'nerves' as presented in a primary care clinic is a lay idiom for emotional distress and documents a relationship between the folk ailment 'nerves' and anxiety and depression. One hundred and forty-nine patients at a Virginia clinic were studied, 47 with 'nerves', and 102 controls. Testing with the General Health Questionnaire (GHQ) and the Beck Depression Inventory (BDI) showed 'nerves' patients to be more anxious and depressed than controls. 'Nerves' patients had a mean GHQ score of 13.0 compared to 5.8 for controls (P less than 0.0001) and a BDI score of 7.6 compared to 2.5 for controls (P less than 0.0001). Testing with the Holmes-Rahe Social Readjustment Rating Scale showed 'nerves' patients to suffer more recent life stresses than controls: 'nerves' patients had a mean score of 187.1 compared to 119.3 for controls (P less than 0.05). 'Nerves' patients had somatic symptoms including gastrointestinal disturbances, headaches and shaking. 'Nerves' is most common among women and housewives, and is often attributed to misfortune and tragedy. The ethnomedical illness 'nerves' encompasses a rich array of cultural meanings reflecting the lifestyle and worldview of its sufferers. Despite its chronic debilitating nature, it is rarely recognized by physicians; it is, however, treated by alternative healers. Clinical implications are discussed and recommendations advanced, among them that physicians work with such healers in the recognition and treatment of 'nerves'.

Standardizing the prothrombin time. Calibrating coagulation instruments as well as thromboplastin.

Recently, indications for anticoagulation with warfarin have increased, prothrombin time (PT) monitoring at offices and homes has become available, and the international sensitivity index (ISI) has been recognized as a means of adjusting for differences in thromboplastins to standardize warfarin sodium dosing. However, different coagulation instruments may yield differences in PTs even after correcting for the ISI by means of the international normalized ratio (INR) (INR = [PT measured ISI/PT normal]). Because the PTs and INRs from our Anticoagulation Clinic (portable PT monitor, ISI = 2.04, normal PT = 12.0 seconds) differed from the hospital reference laboratory (ISI = 2.01, normal PT = 12.0 seconds) despite nearly identical ISIs and equivalent control or normal PTs, we systematically compared the two systems. During a 3-month period, we studied two groups of 50 consecutive patients who had been receiving a stable dose of warfarin. After a single venipuncture, PTs and INRs were measured independently, and regression lines were calculated. Within each group, the results from the different instruments were not identical, but they were highly correlated. In comparing INRs, the regression lines for the separate and combined groups were as follows: group 1 monitor INR = 0.49 reference INR + 0.81, r = .94; group 2 monitor INR = 0.57 reference INR + 0.86, r = .88; and combined monitor INR = 0.49 reference INR + 0.95, r = .89. Only 82% of the differences for all samples were within 1.0 INR units. We concluded that the instrumentation effect may be clinically meaningful, and coagulation instruments as well as thromboplastins should be calibrated to standardize warfarin therapy.

Fatal recreational inhalation of enflurane.

We report here a case of fatal enflurane poisoning by recreational inhalation, apparently the first published report of such a case.

Fatal intoxication involving etryptamine.

A case of fatal intoxication due to the ingestion of Etryptamine (ethyltryptamine) is reported. Toxicological findings included the following tissue distribution: blood (heart) 5.6 mg/L; urine 80.4 mg/L; vitreous 2.4 mg/L; bile 22.0 mg/L; stomach contents 52.9 mg, brain 16.2 mg/g; liver 18.3 mg/g and kidney 24.0 mg/g. Anatomic pathology showed pulmonary edema and generalized visceral congestion with some epicardial petechiae.

A faculty and house-staff group practice: report of an operational model.

The internal medicine group practice at Colorado General Hospital was formed in 1974 to improve patient care and educational experience for residents. Six residents, two faculty members, a nurse practitioner, a dietitian, and a group practice coordinator provide 24 hour-a-day, seven day-a-week care for 666 patients. The program features: a balanced degree of faculty and house staff involvement in direct patient care, a high level of accountability provided by the coordinator, and small group size. The first 19 months of operation are reviewed, and the program is contrasted with other group practices reported in the literature.

Visiting clinician program in primary care internal medicine.

As part of a primary care internal medicine training program, a visiting clinician program was created to improve house staff education, provide an ongoing critique of the training program, and improve communication between program faculty and other institutions. Thirty-one visitors participated in the program during the two years covered by this report. The visitors were effective teachers, and residents noted that teaching by local faculty improved because the visitors demonstrated effective teaching techniques. Visitors made 337 suggestions to improve the primary care medicine program. A telephone survey after the visit indicated that more than half of the visitors had applied ideas from the host institution to their own programs. The program enhanced resident education, provided a periodic review of the training program, and fostered communication with faculty in other programs. The program's evolution over the two years is reported and suggestions are offered for institutions planning similar programs.

"Hidden" popular illnesses in primary care: residents' recognition and clinical implications.

This study documents that ethnomedical beliefs and practices play an important role in primary care in a southern community. Thirty-three of 73 patients from a rural Appalachian area coming to a university primary care internal medicine practice presented 54 ethnomedical complaints such as "high blood" (24.1%), "Weak 'n dizzy" (22.2%), "nerves" (16.7%), "sugar" (5.6%) and "fallin' out" (3.7%). Thirty-three patients had both biomedical and ethnomedical complaints, 40 patients had biomedical complaints without ethnomedical complaints and no patients presented with ethnomedical complaints alone. Over two-thirds of all patients consulted non-medical personnel for their complaints, mostly family and friends, and 70 percent self-treated prior to clinic consultation. Patients presenting with ethnomedical complaints when compared with those presenting with biomedical complaints sought advice of non-physicians significantly more often (p less than 0.02); no statistical difference, however, was found in their self-treatment practices. Ninety-two of 130 biomedical complaints were recorded by the patient's physician but none of the 54 ethnomedical complaints were formally recorded (p less than 0.001). The high incidence of ethnomedical complaints in this population and the failure of physicians to recognize these complaints demand that primary care medicine residents be taught improved history-taking skills and the essentials of ethnomedical illnesses if they are to provide culturally-sensitive patient care.

Anxiety and depression among medical and surgical patients nearing hospital discharge.

Ninety-eight medical and surgical inpatients were interviewed 24-72 hours prior to discharge. Thirty-five (36%) had clinical levels of anxiety and depression as defined by the SCL-90-R, a self-report symptom inventory. Compared with patients with normal SCL-90-R subtest scores, anxious and depressed patients more often had the following characteristics: older age, black race, lower socioeconomic class, a recent previous hospitalization, and impaired functional status prior to admission. Three to four weeks after discharge, 25 of the 35 anxious and depressed patients were again interviewed. Thirteen remained anxious and depressed, while 11 patients had returned to normative distress levels. Older, black, poor inpatients with a recent prior hospitalization and impaired functional status are at high risk for clinical anxiety and depression. Half of those with anxiety and depression may remain anxious and depressed after discharge. Intervention should be considered for these patients.

Lack of effect of warfarin on uric acid concentration.

Uric acid concentrations reportedly are increased in patients being treated with warfarin. We measured uric acid in 40 patients before and during warfarin administration. The mean pre- and post-warfarin uric acid concentrations for our patients were 0.39 mmol/L and 0.40 mmol/L, respectively, not a significant difference. Further observations of hyperuricemic patients started on warfarin are needed to prove that their risk of gout is not increased.

Pulmonary function testing in a general medical practice.

This study examined the feasibility and yield of spirometric screening in a general medicine clinic. Each of 354 randomly selected patients answered a questionnaire on respiratory symptoms and performed pulmonary function tests. Pulmonary testing required approximately two minutes and cost 95 cents per patient. Former smokers who stopped smoking because of symptoms displayed a higher prevalence of abnormalities than expected, and life-long smokers a lower prevalence (P less than 0.001). Fifty-three percent of current smokers had an abnormal pulmonary function test, and forty-two percent of these had no severe pulmonary symptoms. Pulmonary function tests performed in an outpatient clinic are rapid and expensive. Such tests demonstrate a large number of abnormalities which can be used to encourage smoking cessation.

Ofloxacin versus cephalexin for treating skin and soft tissue infections.

Patients with acute localized skin or soft tissue infections were randomized to receive either ofloxacin (300 mg orally, b.i.d.) or cephalexin (500 mg orally, b.i.d.). Among 401 enrolled patients, 382 were evaluable for safety and 148 for microbiologic response. Microbiologic cure occurred in 93.4% of ofloxacin-treated patients and in 94.0% of those treated with cephalexin. Clinical cure or improvement, respectively, was found in 85.2% and 11.1% of patients treated with ofloxacin, and 83.6% and 14.9% of patients receiving cephalexin. Adverse effects (primarily associated with the gastrointestinal tract and central nervous system) were considered to be drug-related in 7.9% of those receiving ofloxacin and 4.8% of those receiving cephalexin. Thus, ofloxacin is as effective and well tolerated as cephalexin and a good alternate antibiotic for treating skin and skin structure infections caused by a variety of pathogens.