Invasive rhino-orbital-cerebral aspergillosis in an immunocompetent patient.

INTRODUCTION: Rhino-orbital-aspergillosis (ROA) is a rare but serious disease in immunocompetent patients. Diagnosis is often delayed due to the absence of specific clinical symptoms. We describe the case of a patient who presented initially with ROA which spread progressively to the right ethmoid-sphenoid sinuses and then to the brain. OBSERVATION: A 61-year-old patient with a history of well-controlled diabetes presented with a sudden severe decrease in right visual acuity. Cerebral MRI showed the presence of an infiltrate in the right orbital apex extending to the homolateral cavernous sinus without any cerebral involvement. A diagnosis of right orbital myositis was made and corticosteroid therapy was started. His symptoms worsened progressively leading to quasi-blindness. A new MRI showed the development of right sphenoid-ethmoid osteolytic lesions. A fungal aetiology was suspected and tests for fungal biomarkers found a ß-(1-3)-D-glucan level of 99pg/ml but negative galactomannan. An ethmoid biopsy was performed for histological and mycological investigations, including the detection of Aspergillus DNA by qPCR. qPCR was positive and culture resulted in the isolation of multi-sensitive Aspergillus fumigatus. Treatment was initiated with voriconazole. Due to persistence of blindness and the appearance of a lesion extending to the right frontal lobe, surgical excision was performed followed by antifungal treatment for a total duration of 1year. The patient is currently stable, but has persistence of blindness in the right eye. CONCLUSION: Invasive ROA is a rare but serious disease in immunocompetent patients which should be evoked in the differential diagnosis of a tumour or vasculitis. Early diagnosis is essential for optimal management.

[Medical decision making in symptoms of type 2 diabetes mellitus in general practice]. / Hausärztliche entscheidungen bei symptomen für diabetes mellitus typ 2.

BACKGROUND: Patient and physician attributes influence medical decisions as non-medical factors. The current study examines the influence of patient age and gender and physicians' gender and years of clinical experience on medical decision making in patients with undiagnosed diabetes type 2. METHOD: A factorial experiment was conducted to estimate the influence of patient and physician attributes. An identical physician patient encounter with a patient presenting with diabetes symptoms was videotaped with varying patient attributes. Professional actors played the "patients". A sample of 64 randomly chosen and stratified (gender and years of experience) primary care physicians was interviewed about the presented videos. RESULTS: Results show few significant differences in diagnostic decisions: Younger patients were asked more frequently about psychosocial problems while with older patients a cancer diagnosis was more often taken into consideration. Female physicians made an earlier second appointment date compared to male physicians. Physicians with more years of professional experience considered more often diabetes as the diagnosis than physicians with less experience. CONCLUSION: Medical decision making in patients with diabetes type 2 is only marginally influenced by patients' and physicians' characteristics under study.

[Influence of patient's age and gender on doctors' decision making about coronary heart disease]. / Einfluss von Patientenalter und Patientengeschlecht auf ärztliche Entscheidungen bei koronarer Herzkrankheit.

BACKGROUND: Studies from the United Kingdom und the United States show that there are variations in doctors' decision making regarding coronary heart disease (CHD) and that patient attributes as well as physician characteristics have an impact on medical decisions regardless of the presented symptoms. This study examines how gender and age of patients influence primary care doctors' diagnostic and management decisions regarding CHD in Germany. METHODS: An experimental design with portrayed videotapes is used. Professional actors play the role of patients with symptoms of CHD. Videotapes were identical apart from varying patients' gender and age (55 vs. 75 years). A randomly selected sample of 128 primary care physicians viewed these videotapes in their practices. Afterwards physicians were asked to describe how to diagnose and treat the patient. RESULTS: Women were less likely to be asked about health related behaviours, less likely to get a CHD diagnosis and less likely to be referred to a cardiologist or other specialist. Younger patients were asked about medical history and smoking more frequently, but they were less likely to be asked about symptoms of pain and discomfort. Moreover, among older patients CHD diagnosis was mentioned more often and with higher certainty and medication appropriate for CHD was prescribed more often. DISCUSSION: Age and gender of patients influence primary care doctors' diagnostic and management strategies relating to CHD in Germany regardless of the presented symptoms.

Sources of variation in physician adherence with clinical guidelines: results from a factorial experiment.

BACKGROUND: Health services research has documented the magnitude of health care variations. Few studies focus on provider level sources of variation in clinical decision making-for example, which primary care providers are likely to follow clinical guidelines, with which types of patient. OBJECTIVES: To estimate: (1) the extent of primary care provider adherence to practice guidelines and the unconfounded influence of (2) patient attributes and (3) physician characteristics on adherence with clinical practice guidelines. DESIGN: In a factorial experiment, primary care providers were shown clinically authentic video vignettes with actors portrayed different "patients" with identical signs of coronary heart disease (CHD). Different types of providers were asked how they would manage the different "patients" with identical CHD symptoms. Measures were taken to protect external validity. RESULTS: Adherence to some guidelines is high (over 50% of physicians would follow a third of the recommended actions), yet there is low adherence to many of them (less than 20% would follow another third). Female patients are less likely than males to receive 4 of 5 types of physical examination (p < .03); older patients are less likely to be advised to stop smoking (p < .03). Race and SES of patients had no effect on provider adherence to guidelines. A physicians' level of experience (age) appears to be important with certain patients. CONCLUSIONS: Physician adherence with guidelines varies with different types of "patient" and with the length of clinical experience. With this evidence it is possible to appropriately target interventions to reduce health care variations by improving physician adherence with clinical guidelines.

[Spondylodiscitis due to Salmonella enteritica serotype Typhi]. / Spondylodiscite à Salmonella enteritica sérotype Typhi.

We reported a case of lombar spondylodiscitis caused by Salmonella enteritica serotype Typhi in an immunocompetent patient. Salmonella is a rare causative agent of spondylodiscitis. Early bacteriological diagnosis is essential to avoid longterm sequelae.

Does bicycling contribute to the risk of erectile dysfunction? Results from the Massachusetts Male Aging Study (MMAS).

An association between bicycling and erectile dysfunction (ED) has been described previously, but there are limited data examining this association in a random population of men. Such data would incorporate bicyclists with varied types of riding and other factors. Data from the Massachusetts Male Aging Study (MMAS) were utilized to examine the association between bicycling and ED. Logistic regression was used to test for an association, controlling for age, energy expenditure, smoking, depression and chronic illness. Bicycling less than 3 h per week was not associated with ED and may be somewhat protective. Bicycling 3 h or more per week may be associated with ED. Data revealed that there may be a reduced probability of ED in those who ride less than 3 h per week and ED may be more likely in bikers who ride more than 3 h per week. More population-based research is needed to better define this relationship.

US public health and the 21st century: diabetes mellitus.

No one can question the remarkable contribution of US public health to understanding the causes and consequences of illness, disability, and death. However, some commentators question the agenda: the endless pursuit of individual risk factors and the cursory attention to social determinants of disease. We attempt to illustrate some limitations of US public health by focusing on type-2 diabetes (adult-onset non-insulin-dependent diabetes)--an increasingly prevalent but still poorly understood medical condition with devastating complications and implications for quality of life. A more theoretically based multilevel approach to diabetes, outlined for the 21st century, has an almost exclusive downstream curative focus, that ranges from midstream preventive programmes to upstream healthy public policy.

Upstream healthy public policy: lessons from the battle of tobacco.

Many consider public health and politics to be entirely separate worlds. Public health activities are generally well-motivated by public interest, perceived as value-free, scientific, and devoid of partisan preference. Politics, in contrast, can be viewed as a distasteful activity involving self-interested pressure groups, misuse of state power, and influence of money on national decisions. Public health and politics are inappropriate bedfellows if politics is reduced to party politics. Politics, of course, involves more than just party activities; it concerns the structure, distribution, and effects of power in society. Which groups pattern the social order? What are their sources of influence? How do they retain privileged status? What social effects result from the policies these groups shape? Viewed in this broader sense, politics is essential for effective public health and thus is the inescapable context of public health interventions. To disregard sociopolitical determinants of health is to relegate public health to prevention and promotion of individual risk behaviors. If public health is to be more successful in the 21st century, it must comprehend the magnitude of the forces against it and the strategies used to engineer its defeat. Public health interventions in the new millennium must be appropriate to their sociocultural context.

To boldly go....

The threshold of the new millennium offers an opportunity to celebrate remarkable past achievements and to reflect on promising new directions for the field of public health. Despite historic achievements, much will always remain to be done (this is the intrinsic nature of public health). While every epoch has its own distinct health challenges, those confronting us today are unlike those plaguing public health a century ago. The perspectives and methods developed during the infectious and chronic disease eras have limited utility in the face of newly emerging challenges to public health. In this paper, we take stock of the state of public health in the United States by (1) describing limitations of conventional US public health, (2) identifying different social philosophies and conceptions of health that produce divergent approaches to public health, (3) discussing institutional resistance to change and the subordination of public health to the authority of medicine, (4) urging a move from risk factorology to multilevel explanations that offer different types of intervention, (5) noting the rise of the new "right state" with its laissez-faire attitude and antipathy toward public interventions, (6) arguing for a more ecumenical approach to research methods, and (7) challenging the myth of a value-free public health.