Fatigue in primary care.

Fatigue is a common problem in primary care that may represent a reaction to life problems or be a component of a disease state. A careful history, physical examination, and a few directed laboratory tests can usually allow the physician to differentiate between fatigue caused by depression, situational stress, or physical causes such as postviral or drug-induced fatigue, endocrine disorders, sleep disorders, infectious diseases, autoimmune disorders, or neurologic disease. Uncommonly, patients may have otherwise unexplained fatigue lasting 6 months or more that fulfills the criteria of chronic fatigue syndrome. A range of diagnostic skills coupled with a therapeutic physician-patient relationship will usually be successful in treating women with symptoms of fatigue.

Chronic fatigue syndrome. Helping patients cope with this enigmatic illness.

Chronic fatigue syndrome is a recurring, debilitating illness complicated by the fact that its diagnosis is largely based on subjective complaints and the absence of reproducibly reliable tests. There is no known "cure" for this illness; however, in general, the prognosis for patients is good. Some physicians accept the existence of chronic fatigue syndrome, while others are convinced that it exists only in the minds of its "victims." The majority of physicians, however, are skeptical but open-minded and wish to help their chronically fatigued patients. As more information comes to light, it is likely that modern medicine will have to rethink its views on this elusive illness. In the interim, patients with chronic fatigue syndrome need the support and reassurance of their physicians to help them cope with their symptoms and resume normal, productive lives.

Telephone medical care of patients with HIV/AIDS.

It has been reported that primary care physicians make 27% of their patient contacts by telephone. With the knowledge that more than 90% of the population has access to a telephone, it is reasonable to propose that the telephone might be employed in a more structured and organized manner for improved, cost-effective medical care. In the current study, two diverse practices (multiphysician and university-affiliated HIV/AIDS clinic, private practice specializing in HIV/AIDS care), both of which used the telephone as having a central role in patient management, were critically observed and reported through three case reports. The results indicate that personnel other than the primary physician provider, such as the triage nurse, may handle a large percentage of calls and successfully manage numerous psychologic and health care issues for the patient, referring, when necessary, appropriate medical inquiries to the physician. It is recommended that physicians take the time to construct sound protocols for clinic personnel to manage patient inquiries by telephone.

Bacteremia in young urban women admitted with pyelonephritis.

The objective of this study was to determine the rate of bacteremia in young women admitted to the hospital with presumed pyelonephritis and compare it with other published rates. The study design was a retrospective, structured chart review and a review of published reports of bacteremic pyelonephritis. An urban county teaching hospital provided the setting for the study. The patients were nonpregnant women (n = 98) 44 years of age or younger who were without bladder dysfunction and who had not been admitted to an intensive care unit. Further criteria for participation included discharge with the diagnosis of acute pyelonephritis. Blood cultures were ordered for 69 women; the results of 64 were noted in the chart. Twenty-three women (35.9% of those cultured; 23.4% of all patients) were diagnosed with bacteremia. In patients for whom blood culture results were obtained, trends developed between those patients with bacteremia and those with complicated pyelonephritis, defined as a known or newly discovered genitourinary abnormality or a risk factor (P = 0.044), those who were black (P = .044), those with higher pulses on admission (P = .050), those with more white blood cells per high-powered field after urinalysis (P = 0.007), and those whose fever lasted longer (P = 0.033). Blood culture results were positive in two patients whose urine cultures were negative. This comparatively high bacteremia rate supports routine ordering of blood cultures for urban women suspected of having pyelonephritis.

Appropriate and inappropriate prescribing of narcotics for ambulatory HIV-positive patients.

OBJECTIVE: To assess the appropriateness of narcotic-prescribing practices in an ambulatory clinic for patients infected with HIV. DESIGN, SETTING, AND PATIENTS: The medical records of 220 (190 HIV-positive) patients, seen in a clinic primarily designed for the long-term follow-up of ambulatory HIV-infected patients and located in an inner-city, public teaching hospital, were retrospectively reviewed to determine the prevalence and appropriateness of prescribing Drug Enforcement Administration schedule 2 narcotics. Appropriateness was based on published guidelines for the use of narcotics in the treatment of cancer patients. MEASUREMENTS AND MAIN RESULTS: The prevalence of narcotic use among the HIV-positive patients was 15%. Narcotics were prescribed for 38% of the patients who died, 33% of those with AIDS [Centers for Disease Control and Prevention (CDC) clinical class C], 4% of those with AIDS-related complex (ARC) (CDC clinical class B), and 5% of asymptomatic HIV-positive patients (CDC clinical class A). None of the HIV-negative patients seen in the clinic received narcotics. Narcotics were more likely to be prescribed for patients with AIDS than for patients with ARC (p < 0.001) or for HIV-positive patients (p < 0.001). For the three CDC clinical classes, there was no significant difference among the proportions of patients receiving narcotics inappropriately (p = 0.108). Among the risk groups, intravenous drug abusers were more likely to be prescribed narcotics inappropriately than were men who were homosexual (p < 0.001) or individuals who were heterosexual (p = 0.013); transfusion recipients were also more likely to be prescribed narcotics inappropriately than were homosexual men (p = 0.026) or heterosexual men or women (p = 0.032). Narcotics were more likely to be prescribed for patients with disseminated histoplasmosis (p = 0.022), Pneumocystis carinii pneumonia (p = 0.001), candidal esophagitis (p = 0.020), Kaposi's sarcoma (p < 0.001), or wasted appearance (p = 0.043). Inappropriate prescriptions were more likely to be given to patients with dementia (p = 0.005) or wasted appearance (p = 0.019). CONCLUSIONS: Physicians tend to prescribe narcotics inappropriately to patients known to have previously abused drugs and to those who appear wasted or have dementia. Physicians have a duty to prescribe narcotics appropriately as guided by recognized medical indications and the patients' views concerning their current medical needs.

Telephone medicine in a southern university private practice.

Routine, office-hour, patient-directed telephone calls to a general and multi-specialty-university, private-practice clinic were surveyed. The calls were short, averaging 1 to 2 minutes. Two-thirds of the calls concerned medications, and 13% were for new medical problems. Patients called with a variety of chronic conditions and less commonly for new problems. Medications such as antihypertensives, antibiotics, and diuretics were prescribed and refilled. The role of telephone medicine in providing access in some managed-care settings is yet to be studied.

Description of a nurse practitioner inpatient service in a public teaching hospital.

A new nurse practitioner service at a public teaching hospital received patients from internal medicine teaching services. To determine the characteristics of the patients, the ratings by the residents, and the professional team costs, the authors performed a case-series study of the first 248 patients. Transferred patients had conditions that necessitated long hospitalizations, most frequently cerebrovascular accident, dementia, and pneumonia. Housestaff rated the service positively. Estimated professional costs were similar to teaching service costs after 15 months. The nurse practitioner inpatient service effectively cared for internal medicine patients with long lengths of stay and received favorable housestaff ratings.

Histoplasmosis as a cause of pleural effusion in the acquired immunodeficiency syndrome.

Disseminated histoplasmosis is an increasingly important opportunistic infection in patients with the acquired immunodeficiency syndrome (AIDS). We report the first case of histoplasmosis as a cause of pleural effusion in a patient with AIDS. Recognition of the typical intracellular yeast on a Wright-Giemsa stained smear of the pleural fluid cells allowed prompt initiation of amphotericin B.

Melioidosis: a reminder.

Recrudescent pulmonary melioidosis developed in two patients 12 and 16 years after their last travels to an endemic area. In one, a clinically silent prostatic abscess may have been the focus; and in both, the diagnosis was difficult to make even when the laboratory was notified of the possibility of infection with Pseudomonas pseudomallei. Recrudescent melioidosis should be considered in febrile patients who have been in endemic areas regardless of the interval from last exposure to the development of disease.

Oral amoxycillin, an alternative treatment for neurosyphilis.

A serum amoxycillin concentration of 0.11 g/l was established as being treponemicidal in a rabbit model with orchitis. Seventeen patients treated with amoxycillin 2 g by mouth three times a day plus 500 mg probenecid twice a day attained treponemicidal CSF amoxycillin concentrations. Thus amoxycillin by mouth offers an effective alternative method for treating patients with neurosyphilis.

Manipulation of stimulus onset delay in reading: evidence for parallel programming of saccades.

On-line eye movement recording of 12 subjects who read short stories on a cathode ray tube enabled a test of direct control and preprogramming models of eye movements in reading. Contingent upon eye position, a mask was displayed in place of the letters in central vision after each saccade, delaying the onset of the stimulus in each eye fixation. The duration of the delay was manipulated in fixed or randomized blocks. Although the length of the delay strongly affected the duration of the fixations, there was no difference due to the conditions of delay manipulation, indicating that fixation duration is under direct control. However, not all fixations were lengthened by the period of the delay. Some ended while the mask was still present, suggesting they had been preprogrammed. But these "anticipation" eye movements could not have been completely determined before the fixation was processed because their fixation durations and saccade lengths were affected by the spatial extent of the mask, which varied randomly. Neither preprogramming nor existing serial direct control models of eye guidance can adequately account for these data. Instead, a model with direct control and parallel programming of saccades is proposed to explain the data and eye movements in reading in general.