Induction of lactic acidosis with intravenous diazepam in a patient with tetanus.

A patient with tetanus was treated with high-dose intravenous (IV) diazepam for control of muscular spasms. As the spasms were controlled with diazepam, lactic acidosis developed. The condition resolved on discontinuation of diazepam therapy and recurred with reinstitution of the drug. To our knowledge, lactic acidosis previously has not been associated with the use of high-dose IV diazepam.

Abdominal computed tomography. Comparison of the usefulness of goal-directed v non-goal-directed studies.

We reviewed the indications for 210 consecutive abdominal computed tomography (CT) scans. One-hundred sixty-six CT scans were done in a goal-directed fashion, whereas 44 were non-goal-directed as part of the evaluation of non-specific abdominal pain, fever, or weight loss. Forty-three percent of CT scans done in a goal-directed fashion revealed new significant information as opposed to only 2% of non-goal-directed studies. Sixteen percent of goal-directed CT scans were normal as opposed to 41% of non-goal-directed CT scans. In at least 16% of cases, abdominal CT scans revealed data confirmatory of information obtained by other modalities. We conclude that abdominal CT scanning used in a non-goal-directed fashion is rarely helpful; however, goal-directed scanning often yields important information.

Defecation syncope. A symptom with multiple etiologies.

To our knowledge, there is no previous clinical description in the literature of patients with defecation syncope. We evaluated 20 patients with this disorder who were a subgroup of a larger, prospective study of syncope, 13 women and seven men, with a mean age of 59 years. Eleven patients had had one episode and nine had experienced multiple episodes. Fourteen patients were recumbent before the urge to defecate, nine of these asleep. The diagnostic evaluation disclosed that two patients had gastrointestinal tract problems, three had cardiac diseases, and one had transient ischemic attacks. Three additional patients had marked orthostatic hypotension. No identifiable cause for defecation syncope was found in 11 patients, but new medical problems were noted in four of those patients. In follow-up at two years, syncope had recurred in ten patients, but the majority of recurrences were unassociated with defecation. Seven patients died during the follow-up period of underlying chronic diseases. We conclude that defecation syncope is not a single distinct clinical entity. Multiple pathologic abnormalities in association with physiologic changes during sleep and defecation may contribute to syncope. Patients with defecation syncope should undergo a careful evaluation for diagnosis of underlying illness causing syncope.

Clinical prediction rules for computed tomographic scanning in senile dementia.

The role of computed tomography (CT) of the head in evaluating patients with dementing illnesses remains a controversial issue. Several prediction rules to guide the selective application of CT in the evaluation of dementia have recently been proposed in the medical literature. The present authors examine the value of four such rules through a validation study performed in an outpatient geriatric assessment unit. The rules were assessed in terms of their diagnostic sensitivities, specificities, misclassification rates, and information contents. Prediction rule sensitivities ranged from 12.5% to 87.5%, specificities from 37.2% to 77.9%, and misclassification rates from 23.5% to 60.8%. Of the four prediction rules examined, one emerged as significantly more sensitive than the others, and also served to reduce diagnostic uncertainty a full order of magnitude more than the others, as determined by an information content analysis. Disadvantages to this rule, however, were found in its more complex nature and the assessment of a very high rate of misclassification. Through a critique of existing strategies, this study purports to determine the potential for establishing a useful clinical prediction rule to guide selective CT scanning in the diagnostic evaluation of dementia.

The duration of Holter monitoring in patients with syncope. Is 24 hours enough?

To determine the incremental yield of ambulatory monitoring in the evaluation of syncope, three serial 24-hour Holter recordings were obtained in a consecutive series of 95 patients with syncope, the cause of which was not explained by history, physical examination, or 12-lead electrocardiogram. The mean age of patients was 61 years and 41% were men. Major electrocardiographic abnormalities were found in 26 patients (27%), including unsustained ventricular tachycardia (19 patients), pauses of at least 2 seconds (8 patients), profound bradycardia (1 patient), and complete heart block (1 patient). The first 24-hour Holter recording had at least one major abnormality in 14 patients (15%) (95% confidence interval, 8.3% to 23.4%). Of the 81 patients without a major abnormality on the first Holter recording, the second Holter recording had major abnormalities in 9 (11%) (95% confidence interval, 5.1% to 20.0%). Of the 72 patients without a major abnormality on the first two Holter recordings, only 3 patients (4.2%) had a major abnormality on the third Holter recording (95% confidence interval, 0.8% to 11.7%). Four factors were significantly associated with an increased likelihood of a major abnormality on 72 hours of monitoring: age above 65 years (relative risk, 2.2), male gender (relative risk, 2.0), history of heart disease (relative risk, 2.2), and an initial nonsinus rhythm (relative risk, 3.5). These results suggest that 24 hours of Holter monitoring is not enough to identify all potentially important arrhythmias in patients with syncope. Monitoring may need to be extended to 48 hours if the first 24-hour Holter recording is normal.

The hospital admission decision for patients with community-acquired pneumonia. Results from the pneumonia Patient Outcomes Research Team cohort study.

BACKGROUND: The hospital admission decision directly influences the magnitude of resource use in patients with community-acquired pneumonia, yet little information exists on how medical practitioners make this decision. OBJECTIVES: To determine which factors medical practitioners consider in making the hospital admission decision and which health care services they believe would allow ambulatory treatment of low-risk hospitalized patients with community-acquired pneumonia. METHODS: Medical practitioners responsible for the hospital admission decision for low-risk patients with community-acquired pneumonia were asked to describe patient characteristics at initial examination that influenced the hospitalization decision, and to identify the health care services that would have allowed initial outpatient treatment of hospitalized patients. RESULTS: A total of 292 medical practitioners completed questionnaires for 472 (76%) of the 624 low-risk patients eligible for this study. Although all patients had a predicted probability of death of less than 4%, practitioners estimated that 5% of outpatients and 41% of inpatients had an expected 30-day risk of death of more than 5%. Univariate analyses identified 3 practitioner-rated factors that were nearly universally associated with hospitalization: hypoxemia (odds ratio, 173.3; 95% confidence interval, 23.8-1265.0), inability to maintain oral intake (odds ratio, 53.3; 95% confidence interval, 12.8-222.5), and lack of patient home care support (odds ratio, 54.4; 95% confidence interval, 7.3-402.6). In patients without these 3 factors, logistic regression analysis demonstrated that practitioner-estimated risk of death of more than 5% had a strong independent association with hospitalization (odds ratio, 18.4; 95% confidence interval, 6.1-55.7). Practitioners identified home intravenous antibiotic therapy and home nursing observation as services that would have allowed outpatient treatment of more than half (68% and 59%, respectively) of the patients initially hospitalized for treatment. CONCLUSIONS: Practitioners' survey responses suggest that the availability of outpatient intravenous antimicrobial therapy and home nursing care would allow outpatient care for a large proportion of low-risk patients who are hospitalized for community-acquired pneumonia. These data also suggest that methods to improve practitioners' identification of low-risk patients with community-acquired pneumonia could decrease the hospitalization of such patients. Future studies are required to help physicians identify which low-risk patients could safely be treated in the outpatient setting on the basis of clinical information readily available at presentation.

Diagnostic and prognostic implications of recurrences in patients with syncope.

The incidence and the diagnostic and prognostic implications of recurrences in 433 patients enrolled in a prospective syncope study are reported. Over a mean follow-up of 30 months, 146 patients had recurrent syncope. Patients with an initial diagnosis of a cardiovascular cause of syncope had a recurrence rate of 31 percent, patients with a noncardiovascular cause had a recurrence rate of 36 percent, and patients with syncope of unknown origin had a recurrence rate of 43 percent at three years (these differences were not significant; the minimum for any two-way comparison was p greater than or equal to 0.11). In eight of the 191 patients in whom a cause of syncope could not be found on initial evaluation, a diagnosis was assigned in follow-up after recurrent syncope. Recurrences led to major morbidity in eight of 146 patients (5 percent) and minor trauma in 10 patients (7 percent). Using recurrence as a time-dependent variable in the Cox models, it was found that this variable was not a significant predictor of overall mortality or sudden death. It is concluded that recurrences are common in patients with syncope, but new diagnosis are rarely established on the basis of evaluation of recurrences. Recurrences are not predictors of mortality or sudden death.

Prolonged electrocardiographic monitoring in patients with syncope. Importance of frequent or repetitive ventricular ectopy.

The purposes of this study were to document the findings on prolonged electrocardiographic monitoring in patients with syncope, correlate these findings with symptoms during monitoring, and define the prognostic importance of these findings. A total of 235 patients with syncope in whom a cause was not assigned or suggested by the initial history, physical examination, and electrocardiography were studied. Although a variety of arrhythmias were documented during monitoring, the vast majority of arrhythmias were of short duration and did not produce symptoms. At two years, the patients with frequent or paired premature ventricular contractions (PVCs) when compared with patients with rare PVCs, had a higher incidence of sudden death (18.2 percent versus 4.0 percent; p less than 0.001) and higher overall mortality (28.3 percent versus 10.8 percent; p less than 0.003). Similarly, patients with ventricular tachycardia, when compared with patients with rare PVCs, had a higher incidence of sudden death (18.7 percent versus 4.0 percent; p less than 0.0001) and higher overall mortality (36.5 percent versus 10.8 percent; p less than 0.00001). Cox regression analyses revealed that frequent or repetitive PVCs and sinus pauses were independent electrocardiographic predictors of sudden death and mortality in patients presenting with syncope. Therefore, patients with syncope and frequent or repetitive ventricular ectopy or sinus pauses constitute a high-risk subgroup and may be candidates for more extensive diagnostic evaluation.

Syncope in the elderly.

This report describes the evaluation of syncope in 210 elderly patients as compared with 190 younger patients. The elderly group had a mean age of 71 years (range 60 to 90) and the younger group had a mean age of 39 years (range 15 to 59). A cardiovascular cause was found in 33.8 percent of the elderly and in 16.8 percent of the young (p = 0.0001), a noncardiovascular cause in 26.7 percent of the elderly and 37.9 percent of the young (p = 0.02), and unknown cause in 38.5 percent of the elderly and 45.3 percent of the young (NS). Prolonged electrocardiographic monitoring established the diagnosis in 17 percent of the elderly but in only 8 percent of the young (p = 0.008). Syncope resulted in trauma in 39 percent of the elderly and in 32 percent of the young, but the elderly more often had major trauma. The two-year overall mortality was 26.9 +/- 3.4 percent in the elderly and 8.3 +/- 2.1 percent in the young (p less than 0.0001). The overall mortality and incidence of sudden death in the elderly with a cardiovascular diagnosis were similar to those in the young; however, in the elderly with a noncardiovascular diagnosis and syncope of unknown cause, the mortality and incidence of sudden death were higher. Multivariate analyses using mortality and sudden death as endpoints revealed that a cardiovascular cause of syncope was a very strong risk factor. In patients with a noncardiovascular cause or unknown cause of syncope, a history of congestive heart failure, older age, and male sex are important prognostic factors.

Ventricular arrhythmias during Swan-Ganz catheterization of the critically ill.

The incidence of ventricular arrhythmias in critically-ill patients during bedside right-sided heart catheterization with a flow-directed balloon-tipped catheter was determined. Twenty-nine of 60 catheterizations (48 percent) were associated with premature ventricular contractions and 20 (33 percent) were associated with ventricular tachycardia. Two patients required antiarrhythmic therapy or a precordial thump to convert ventricular tachycardia. One patient developed ventricular tachycardia and fibrillation and died. Serious catheter-induced arrhythmias, including sustained ventricular tachycardia, may occur during Swan-Ganz catheterization of the critically ill.

Community-based geriatric assessment.

A comprehensive review of the multidisciplinary functional assessment and treatment of 800 patients seen at a community-based geriatric assessment center was performed to profile clinical characteristics of patients attending such a program and to evaluate possible predictors of institutionalization. The most common problems addressed were senile dementia (46%), hypertension (31%), clinically significant depression (30%), and burdened caregiver (24%). More than 90% of patients were able to remain in the community after multidisciplinary treatment of their problems and marshalling of support services. The most potent predictors of institutionalization in rank order of predictive value were: falls or unstable gait, senile dementia, caregiver strain, lack of support services, and moderate to severe impairment of ability to perform activities of daily living (multiple R = 0.45; P = .001). Advantages and impediments to community-based assessment are discussed.

Anisakiasis: nematode infestation producing small-bowel obstruction.

A case of small-bowel obstruction occurred secondary to an uncommon parasitic disease, anisakiasis. Intestinal obstruction is a rare manifestation of this disease. Anisakiasis may be seen initially with nausea and vomiting or may mimic acute appendicitis or Crohn's disease. The predisposing factor in all cases is the ingestion of raw fish, and the disease is preventable by cooking fish at greater than 60 degrees C for a short time or by freezing at less than -20 degrees C for more than 24 hours. Anisakiasis should be considered in the differential diagnosis of small-bowel obstruction in patients whose diet includes raw fish.

The decade of the nineties at the UCLA Medical Center: responses to dramatic marketplace changes.

The evolution of the health care marketplace in the nineties in Southern California is described, including the dominance of managed care at the decade's end. The marketplace, especially in Los Angeles, is now one of the most complex, competitive, and challenging medical marketplaces in the country. The University of California, Los Angeles (UCLA) Medical Center and the academic health center of which it is a part have had to respond appropriately and vigorously to survive and to position themselves for the future. This article focuses on the responses of the medical center to these marketplace pressures. The center has recognized single-signature contracting, cost containment, and an emphasis on ambulatory care as fundamental success factors for survival in a complex, organized managed care environment. Data on the medical, financial, and educational performances of the medical center are presented in terms of its responses to the marketplace. Preliminary information about quality of care is presented for three patient-population groups that have been heavily affected by managed care. The need for emphasis on quality and service for future success and the attendant need for emphasis on information systems are discussed. The importance of fundamental understanding of markets is also reviewed. The concomitant approaches to securing the center's academic missions are described, including changes in institutional governance for the entire health sciences center of which the medical center is a part and the establishment of priorities in research, clinical care, and teaching programs, especially teaching programs in primary care.

Development of a central division of general internal medicine.

A division of general internal medicine was, by design, developed to be central to many of the activities of the department of medicine. Since 1979 the division has grown from five faculty members to 29 members and has the potential for substantial additional growth. The division provides approximately 70% of all inpatient teaching by attending physicians, provides all of the general medicine outpatient teaching, and has substantial impact on medical student training programs. The division is responsible for more than $1.5 million of clinical services and approximately 10% of hospital admissions, and it is responsible for approximately 40% of all patients on the general medicine service. Research activities are divided into several distinct modules, including medical informatics, clinical epidemiology, occupational medicine, geriatrics, medical competency testing, and ethics. The division receives approximately $1.2 million from external sources, including the federal government and foundations, for its research activities. Because of its success, it may serve as a potential model for similar divisions in other departments of medicine.

Superior vena cava syndrome: diagnostic procedures.

The hospital records of patients discharged from Presbyterian-University Hospital of Pittsburgh with the diagnosis of superior vena cava syndrome (SVCS) were reviewed in order to determine if diagnostic procedures were associated with an unacceptable risk of complications. Fifty-six cases were reviewed. Symptoms had been present for an average of five weeks. Forty-five patients underwent diagnostic tests including sputum cytology, lymph node biopsy, bone marrow biopsy, bronchoscopy, mediastinoscopy and thoracotomy. The diagnostic yield of these procedures ranged from 28% (cytology) to 100% (thoracotomy). Complications occurred only with mediastinoscopy and none of these were fatal or caused long-term morbidity. We conclude that most patients with SVCS (excepting those with neurologic or respiratory compromise) can tolerate a vigorous pursuit of a histologic diagnosis before therapy is instituted.

[The demonstration of the cruciate ligaments by xerotomography (author's transl)]. / Die Darstellung der Kreuzbänder durch die xeroradiographische Tomographie.

Demonstration of the cruciate ligaments by xerotomography was attempted in 54 patients after double contrast arthrography of the menisci. The best results of lateral tomography were achieved in showing the middle and caudal portions of the anterior ligament. The ligaments close to the femur are not well demonstrated. Twenty-six patients underwent operation; of these, 13 had ruptured cruciate ligaments. The correct diagnosis was made by xerotomography in only 46%. The reasons for this are discussed. The present results do not suggest that Xerotomography is valuable in the diagnosis of abnormalities of the cruciate ligaments.

[A correlative retrospective study of the histological findings and arthrograms in degenerative disease of the meniscus (author's transl)]. / Die korrelation histologischer Befunde bei degenerativen Meniskusveränderungen zum Arthrogramm-Eine vergleichende retrospektive Studie.

The ability to diagnose degenerative changes of the menisci by means of arthrograms was studied retrospectively by correlating the histological and operative findings and arthrographic appearances in 45 cases. It was shown that degenerative changes, as indicated histologically, could be diagnosed by arthrography, but that the arthrogram gave no certain indication of its severity. On the other hand, it appears that fairly severe changes must be present before they become radiologically visible. In negative cases the presence of degenerative changes in bone and cartilage may indicate meniscus degeneration. Problems in the diagnosis of cartilage abnormalities in the arthrogram are discussed.

Deep venous thrombosis of the upper extremity five years experience at a university hospital.

All patients with deep vein thrombosis of the arm seen at one University Hospital over a 5 year period were reviewed. The 17 cases could be divided into distinct patient groups. The first group (primary thrombosis) consisted of 7 patients primarily healthy young males (mean age 23) who had vocations or avocations which involved vigorous physical activity of the arms. The 10 patients with secondary thrombosis tended to be older (mean age 47.3) and to be ill or hospitalized at the time of onset of their illness. Followup information could be obtained in 9 of the cases and 7 of these patients had persistence in their symptoms consisting of residual discomfort and edema of the involved arm especially after exercise. None of the patients treated with anticoagulation were asymptomatic. The only patients who were symptomatic were one patient who received streptokinase and another who underwent thrombectomy. Three illustrative case studies are included.

Syncope in the elderly: a pragmatic approach.

Carotid massage should be performed in elderly patients only if other diagnostic studies have not been helpful, since in rare instances, transient and permanent neurologic deficits have been precipitated by this maneuver. Patients with auscultatory findings of cardiovascular disease should certainly undergo further evaluation with appropriate studies such as echocardiography, stress testing, or cardiac catheterization.