Status epilepticus after cranial CT with contrast media.

This case illustrates intravenous radiographic contrast material as an unusual and little known etiology of seizure. A brief review of the literature is provided in which the incidence of contrast induced seizures and the potential risk factors for their development are discussed.

Doxapram in hypercapnic chronic obstructive pulmonary disease with respiratory failure.

An 81-yr-old man with severe chronic obstructive pulmonary disease and hypercapnia presented to the emergency department (ED) obtunded and in acute respiratory distress. He had instructed his family to refuse intubation but agreed to all other measures to sustain his life. Treatment measures included the administration of intravenous doxapram, which was followed promptly by a marked improvement in his respiratory function and mentation. Respiratory stimulants may be useful as a temporizing measure in this difficult ED therapeutic problem.

Ureteral stent displacement associated with deep massage.

A 51 year-old woman with a history of ureteral stenosis and calculi noted recurrence of severe left flank pain while undergoing a deep body massage using the Rolfing method. Displacement of her left ureteral double J stent was noted in the emergency department. The pain and associated incontinence resolved with restoration of the stent to its original position. Practitioners should be aware of this potential complication related to forceful massage pressures.

Hearing loss in former prisoners of war of the Japanese.

OBJECTIVE: To describe the prevalence, degree, and types of hearing loss present in a group of older American veterans who had been prisoners of war of the Japanese. DESIGN: A descriptive study. SETTING: A Veterans Affairs university hospital. PARTICIPANTS: Seventy-five male veterans, mean age 68 (+/- 3.6) years. INTERVENTIONS: Hearing aids were prescribed for eight veterans. MEASUREMENTS: Subjects were examined, and pure tone air and bone conduction, speech reception threshold, and speech discrimination were determined. Results were compared with age- and sex-matched controls from the largest recent American population study of hearing loss. RESULTS: 95% of subjects had been imprisoned longer than 33 months. Starvation conditions (100%), head trauma (85%), and trauma-related loss of consciousness (23%) were commonly reported. A total of 73% complained of hearing loss, and 29% (22/75) dated its onset to captivity. Most of those with the worst losses in hearing and speech discrimination were found in this subgroup. When the entire group was compared with published age- and sex-matched controls from the Framingham Study, no significant differences were found. CONCLUSIONS: We advocate screening examinations and long-term follow-up of populations with similar histories of starvation, head trauma, and torture.

Interhospital transfers, the COBRA Law (1985), and the use of a public assistance health plan.

Public outcry regarding unsafe interhospital patient transfers led to the passage of the COBRA Law of 1985. Since its implementation in 1986, the law has been sharply criticized for its sporadic enforcement, narrow focus, and lack of care provisions for the poor. We reviewed retrospectively the charts of all emergency department patients transferred from two Milwaukee private hospitals during two identical 6-month periods in 1985-1986 and 1988-1989. We compared demographic and clinical characteristics of the patients transferred during the two periods. The emergency departments cared for 15% of Milwaukee's emergency patient population and transferred 216 and 200 patients during each respective period. Uninsured transfers fell from 32% to 17% of the study populations. Although the proportion of the local population belonging to a health maintenance organization (HMO) did not change, transfer of HMO patients increased from 14% to 27%. Transfers to the area's various tertiary care centers made up 21% and 35% of all transfers and were conducted without regard to insurance status. There was a fourfold increase in the use of the county's public assistance plan for emergency hospitalization of indigent patients at local hospitals. Although the number of uninsured patients transferred from the study hospitals decreased markedly, this decrease was counterbalanced by increased private hospital use of the county's emergency hospitalization plan for indigent patients. This successful plan bears further examination by health policy planners as an important model for the provision of emergency hospitalization for the indigent.

Case report: potentiation of warfarin by fluconazole.

Described is an elderly woman who developed gastrointestinal bleeding probably potentiated by the interaction of fluconazole with warfarin. Because varied clinical uses are being found for fluconazole, clinicians should be aware of this potential interaction.

White liver: a cultural disorder resembling AIDS.

Hoodoo is a folk belief system common among black Americans. Conjuration and rootwork are other terms used to describe this system which includes the casting of spells and witchcraft. This paper describes the black folk concept of 'white liver', an aspect of hoodoo which bears striking resemblance to AIDS. White liver refers to a condition characterized by sexual excess and a wasting to death of sexual partners. Although clearly antedating by many years the current AIDS epidemic, white liver is important as a contemporary black cultural entity that may be used to describe AIDS or to articulate a fear of AIDS.

Hamate-metacarpal fracture dislocation.

A patient is described who punched a brick wall with his clenched fist and sustained a fracture of the body of the hamate with dislocation of the ring and little finger metacarpals. He was treated successfully with surgery. This is a rare injury that is frequently missed on the initial presentation and should be considered in the differential diagnosis of posttraumatic ulnar-sided hand pain.

Lymphangiosarcoma associated with lymphedema in a man with Maffucci's syndrome.

A man with Maffucci's syndrome and lifelong lymphedema in the right lower extremity had a lymphangiosarcoma in the same extremity. Despite amputation of the limb and radiotherapy, he died several months later of pulmonary metastases. Malignancies of vascular origin rarely have been reported in this syndrome. Our patient's features suggest that lymphedema may predispose patients with Maffucci's syndrome to the development of lymphangiosarcoma.

Nursing home patients transferred by ambulance to a VA emergency department.

Nursing home residents are frequently transferred to hospital emergency departments. Delayed transfer may lead to poor outcomes. However, inappropriate transfer of the frail elderly may cause social and financial problems. We prospectively evaluated 221 consecutive ambulance transfers from community nursing homes to a VA emergency department. The objectives of the study were to describe the process and outcomes of transferred patients and to determine if alternative interventions were feasible. The results indicate that the problems of nearly half the study group could have been treated at the nursing home by a visiting physician with minimal medical equipment. Those admitted to the hospital (52%) were seriously ill, had prolonged lengths of stay (23.6 days), and had a high mortality rate (11%). Complex issues of physician reimbursement, proprietary nursing home budgeting, and day-to-day expediency appear to be involved in decisions to transport patients by ambulance to VA emergency departments.

Segond fracture, hemarthrosis, and anterior cruciate ligament disruption.

A case of anterior cruciate ligament disruption in a patient with an avulsion fracture of the lateral proximal tibia is presented. The "Segond" fracture is an unusual fracture that is important to recognize because it is often associated with anterior cruciate ligament disruption and anterolateral instability. These injuries are usually best treated by early surgical repair.

Cocaine and scleroderma.

I have described a patient with scleroderma whose sex, age at onset of symptoms, and history of long-term intravenous use of cocaine suggest a possible causative role of cocaine in his disease.

Community hospital transfers to a VA Medical Center.

We prospectively studied all transfers from community hospitals to the Zablocki Veterans Administration Medical Center in Milwaukee (Wis) between May 28, 1986, and January 1, 1987. Transfers totaled 4.7% (311/6609) of acute-care admissions during the study period but accounted for 19.1% (39/204) of in-hospital deaths. The mortality rate for transferred patients who required Veterans Administration hospitalization was 12.5% (39/311) compared with 2.6% (165/6298) for all other admissions. At the time of transfer 59 patients (19%) were judged unstable by a modification of the APACHE II classification system, yet only 19 patients were cared for en route by a physician or a nurse. In addition to higher mortality, the transferred patients had a longer median length of stay than nontransferred patients (11 days vs 7 days).