Tuberculosis screening in medical students.

BACKGROUND AND OBJECTIVES: The Liaison Committee on Medical Education and the Association of American Medical Colleges have issued recommendations for screening medical students for tuberculosis. This report describes the initiation of a tuberculosis screening program at the F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences (USUHS). METHODS: A screening program was instituted in 1993 that included intradermal purified protein derivative, the "booster phenomenon," inter-reader variability, risk factor analysis, and administrative policy to improve compliance. RESULTS: There were 501 students screened (classes of 1996-1998). Initially, 19 (3.8%) students' tests were classified as positive, and 14 additional students tested positive when tested again 2 months later, due to the booster phenomenon. The subsequent conversion rate was 2.5% for those students who were followed for the next 3 years of medical school. All these students were placed on prevention therapy with isoniazid. No active cases of tuberculosis have been identified since the inception of the screening program. DISCUSSION: Only recently has the importance of screening medical students been emphasized. The USUHS program was designed to address the factors for a successful screening program, such as increased compliance, standardization, and documentation. With modifications according to resources, medical schools can offer an efficient tuberculosis screening program to students, faculty, and staff.

Evaluation of pediatric foot problems: Part II. The hindfoot and the ankle.

The bony development of the growing child can lead to a variety of hindfoot and ankle problems. Overuse injuries are common, often occurring in conjunction with symptomatic pes planus and plantar fasciitis. Predisposing structural differences such as Haglund's disease, os trigonum, rigid and flexible pes planus, and Sever's disease merit special attention, but treatment may require only patient education and conservative management. Sprains and fractures of growing joints, however, may have poor outcomes if ignored or missed.

Evaluation of pediatric foot problems: Part I. The forefoot and the midfoot.

Foot problems in children can be the result of infection, trauma or overuse. Ingrown toenails, bunions, sesamoid disease, congenital overriding of the fifth toe, and fractures may occur in both adults and children. Some disorders, such as Freiberg's infarction and Kohler's disease, however, are unique to the pediatric population. The potential for adverse sequelae is greater in children than in adults. A thorough understanding of the anatomy of the pediatric foot and a systematic examination will facilitate the diagnosis of pediatric foot problems. A conservative approach to management will improve both compliance and outcome.

Dimensions of happiness: a qualitative study of family practice residents.

BACKGROUND: Happiness is related to both positive and negative forces. Positive factors, or happiers, that compensate for stressors in residency have only recently been recognized in a pilot study of 14 family practice residents. These happiers are positivism, the pursuit of goals, relationships, a religious belief system, and feedback. The purpose of this qualitative study was to describe happiers of residency in family practice in each postgraduate year and relate the findings to established theories on well-being. METHODS: A qualitative interview with participant observation was used to study 59 residents at four family practice residency sites. Interviews were semistructured and audiotaped. Tapes and field notes were analyzed for trends. The Faces Scale was administered as a happiness visual analog scale. RESULTS: The importance of a well-balanced lifestyle, as well as the pursuit of goals, relationships, and accentuation of the positive, were found to be happiers for all residents interviewed. Religious commitment, feedback, and a sense of control or autonomy were important to the level of happiness of more than 60 percent of residents interviewed. Feedback was more important to 1st-year residents, and a sense of control was more important to 2nd-year and 3rd-year residents. CONCLUSION: The seven happiers described in this study were similar to happiness factors reported in the social science literature. Our findings could contribute to theories of resident well-being and further the research on well-being in residency training.

The Marfan syndrome. An underdiagnosed killer.

The Marfan syndrome is an inherited connective-tissue disorder. The sequela of the syndrome is premature death that is most often due to cardiac complications and that can be prevented with early diagnosis and aggressive management. Although research has identified a gene responsible for the myriad of phenotypic presentations, the diagnosis of Marfan syndrome remains clinical. The family physician is well positioned, with consultation from an experienced cardiac surgeon, to orchestrate the diagnosis and management of the Marfan syndrome.

Osteopetrosis ('marble bone' disease).

Osteopetrosis is a hereditary disorder in which pathologic alteration of osteoclast resorption of bone results in thickening of cortical and lamellar bone. Before bone marrow transplantation, the infantile recessive form was uniformly fatal within the first two decades of life as a result of invasion of the marrow space by abnormal bone formation. The adult autosomal dominant form causes minimal morbidity and is usually diagnosed incidentally on routine radiographs. Although osteopetrosis is an extremely rare disorder, the study of this disease can provide insights into the formation of bone and the inheritance of disease.

Acute trauma and hypnosis.

Hypnosis is a valuable adjunct to the management of acute trauma. This is a case presentation of the management of severe burn injuries after fire and explosion on a United States Navy vessel. Hypnosis was used to calm one patient and facilitate intubation. Further suggestions of rapid healing and anxiety control were given. Hypnosis is not only helpful for management, but can be used to decrease the perceived severity of the incident. Patient well-being may also prevent sequelae of stress.

Orofacial pain: diagnosis and treatment.

Orofacial pain can have an inflammatory, neurologic or musculoskeletal cause. Inflammatory diseases include dental abscess, sinusitis, temporal arteritis, sialolithiasis and infections of the parotid gland. Common neurologic diseases that cause facial pain are trigeminal neuralgia, glossopharyngeal neuralgia, paratrigeminal neuralgia and cluster headaches. Musculoskeletal causes include temporomandibular joint syndrome and myofascial pain dysfunction syndrome. A clear understanding of pertinent anatomy and an organized approach to diagnosis will facilitate the evaluation of patients with orofacial pain.

Clinical applications of hypnotherapy.

Hypnosis has been used as a therapeutic tool for centuries, but only in the past 50 years have the clinical applications been delineated. As evident in the medical literature, the use of hypnosis by the medical community has increased, partly as a result of a growing awareness of hypnotherapy as an available treatment modality, and also as a result of major improvements in research methodology through strict standardization. Hypnotherapy, once considered to be limited to entertainment, has now proven useful in the treatment of a wide variety of medical illness. Two cases of the use of hypnosis are presented. In the first case, hypnosis is used to alleviate pain in a gravid patient in sickle cell crisis. In the second case, hypnosis is used for desensitization of dental phobia in a 27-year-old women. The historical, theoretical, and clinical applications of hypnosis are reviewed.

Orthopedic trauma: a family practice perspective.

It is well documented that residency-trained family physicians can effectively manage the majority of nonsurgical acute orthopedic injuries with a relatively small rate of consultation. The frequency of both fracture location and orthopedic review in our series are remarkably similar to the study from NRMC Charleston reported in 1981. Our program, however, is unique because of the comprehensive management, 3-year continuous training, and multidimensional educational experience. A critical element to the program is the excellent working relationship shared by the family practice and orthopedic departments. A clinic similar to the Davis Grant USAF Medical Center cast clinic could be implemented easily and would better train the family practice resident to manage nonsurgical orthopedic trauma.

Hyperhidrosis: a management dilemma.

Hyperhidrosis is excessive sweating in response to psychological stress and emotional stimuli. The sweat is usually limited to the palms, soles, and axillae, and is greatly accentuated by mental stimuli rather than temperature and exercise. The severity is such that for many, sweating has become socially and emotionally devastating and may predispose to other cutaneous diseases. More than 60 research papers on eccrine glands and sweating have been published since 1978. Little progress, however, has been made on the control of hyperhidrosis, and the process remains a treatment dilemma among both family physicians and dermatologists. The many treatment modalities documented in the literature have been for the most part unsuccessful or unacceptable. This report describes the use of phenoxybenzamine, an alpha-adrenergic antagonist, for control of excessive sweating in two patients. After a trial of topical medication, phenoxybenzamine is useful for the reduction of sweating to an acceptable level.

Late-life migraine accompaniments: a case presentation and literature review.

Migraine headaches that occur in the 15- to 30-year-old age group are well documented. In patients in the stroke age bracket, however, who present with a history of neurologic deficit, transient ischemic attacks can be confused with migraine accompaniments. The typical patient is 50 years old, is without a past history of migraines, and complains of scintillating visual disturbances (20 percent), marching paresthesis (22 percent), or a myriad of neurologic deficits. In one series of 70 neurology patients aged over 55 years, 16 percent reported that they experience the new onset of scintillations. Once fully evaluated, the cause of unexplained marching paresthesias, dysphagia, or hemiplegia, once reserved for thrombotic or embolic phenomena, may be attributed to migraine accompaniments. In the face of a normal evaluation, neurologic deficit in the stroke age bracket may be attributed to migraine accompaniments. A case of a 47-year-old woman with sudden onset of left-sided paresthesia, dysarthria, and confusion is presented. The discussion includes a description of migraine pathophysiology and a review of concepts regarding accompaniments.