Adult constipation: a review and clinical guide.

Constipation is a common complaint that can be a symptom of serious disease. Awareness of the potential etiologies can help direct the history, physical exam and subsequent work-up for the presenting individual. This article details the differential diagnosis and pathophysiology of constipation based on a review of the literature. The article is also designed to be useful as a guide to the work-up of constipation. Key elements of the history, physical exam and testing are outlined. Included is a detailed flow diagram to guide the work-up of constipation. Testing methods and their value in the evaluation of chronic idiopathic constipation are discussed. Finally, although the focus of this article is the evaluation of constipation, a section on the treatment of constipation is included.

Colorectal cancer: update on recent advances and their impact on screening protocols.

As the third leading cause of cancer cases and deaths in the United States, colorectal cancer has been an area of intense interest. The objectives of this article are, through a review of the literature published between 1995 to 1998, to examine current trends in the epidemiology of colorectal cancer, new information on genetic, dietary, and other risk factors; to evaluate the effectiveness of current screening guidelines for various populations; to review information on chemoprevention; and finally to examine new concepts on the horizon in the area of colorectal cancer research. Much of the recent research in the field has focused on etiology, dietary, and other risk factors. Many genetic factors have been discovered, which serve to elucidate the mechanism of pathogenesis of colorectal cancer as well as offer possible targets for treatment strategies. Dietary and risk factors for colorectal cancer may pave the way for chemoprevention. In light of the most recent information on colorectal cancer, one is able to more accurately assess current screening guidelines for their effectiveness in all populations based on epidemiologic data, as well as evaluate more novel screening strategies for their possible utility in the future. In addition to a review of the most up-to-date literature, the authors also provide their recommendations for screening based on the evidence in which the review of the literature provides. Finally, current and future treatment options are discussed. It is our hope that the physicians will find this review useful in the evaluation and care of patients at risk of developing colorectal cancer.

Tumor markers. An update.

Cancer remains the second leading cause of death in developed countries, and the incidence of certain tumors is increasing despite emphasis on prevention and screening. Tumor markers are biologic or biochemical substances that are produced by tumor cells and then secreted into the circulation in detectable amounts. This article covers some of the more common tumor markers currently being utilized for diagnostic and prognostic purposes.

Colorectal cancer. A practical review for the primary care physician.

Colorectal cancer is a common disease in the United States. In the past 30 years, only limited improvements in stage of disease at the time of diagnosis and survival rates have been made. Research into genetic, environmental, and diet-related risk factors is promising but insufficient to serve as a foundation for preventive advice. The slowly progressive adenoma-carcinoma sequence is now commonly accepted. The American Cancer Society, Atlanta, Ga, and the National Cancer Institute, Bethesda, Md, advocate screening with annual fecal occult blood testing plus sigmoidoscopy every 3 to 5 years in persons 50 years old and older. The development of more cost-effective screening strategies is under study, with emphasis on targeting high-risk populations, determining optimal screening intervals, identifying the length of colon to study and by what means, and determining the surveillance needed in individuals who have had polyps removed.

Does early clinical exposure enhance performance during third-year clerkship?

This study was undertaken to assess the effects of early clinical exposure in an indigent care free clinic on third-year clerkship mini-board scores (clinical knowledge), faculty evaluation (especially rapport with colleagues and patients), and final rotation grades. After completion of third-year clerkships, a sample of participants was compared with nonparticipants. Comparative statistics, repeated measure analysis, and analyses of variance were performed on the entire group as well as by sex and by individual rotation. No statistically significant differences were found in the mainframe, but subgroup findings indicate further study is warranted. Negative findings might be explained in part by small sample size and the fact that the clinic is exclusively outpatient, while the third-year clerkship experience is inpatient. Data collection is being continued, and studies are ongoing to look at the long-term effect of the program on participants.

Biliary extracorporeal shock-wave lithotripsy: an update.

Since the mid-1980s, numerous clinical studies, involving hundreds of patients, have attested to the safety and efficacy of this technique. There have been no deaths, and occasional soft tissue damage appears to be temporary.

The effects of certain student and institutional characteristics on minority medical student specialty choice.

This article investigates the possible effects of minority status, presence of a Minority Affairs Office or Student National Medical Association (SNMA) Chapter, level of indebtedness, and number of years (4 to 5) to complete medical school on specialty choice of minority medical students. The 5-year experiences of 20 medical schools in the southern region (including three in Puerto Rico) were examined via a questionnaire. Information was sought for African Americans, Afro-Caribbean, Mexican American, other minority, and nonminority students. Minority graduates entered the specialities of internal medicine, pediatrics, and family medicine in far greater numbers than any other speciality. Also, the percentage of minorities who entered these fields was greater than the percentage of non-minorities. Conversely, minorities were significantly underrepresented in the surgical subspecialties and radiology. Additional study is needed to further examine the medical school experience for indications of why the clustering in primary care specialities occurs. Moreover, while most schools had some kind of minority affairs organization, few were active in the writing of the Dean's letter. Other suggestions to assure adequate minority representation across specialties include early exposure to the different specialties and subspecialties for minority students, a mentorship program with practicing physicians, and stronger recruitment of minorities into underrepresented specialties.

Seasonality of Chlamydia trachomatis genital infections in university women.

Previous studies have shown seasonal fluctuations in the incidence of most sexually transmitted diseases, with a peak in the third quarter, but none have specifically evaluated Chlamydia trachomatis genital infections. From 1989 to 1991, 8,234 women presenting to the student health centers of Florida's two largest universities for routine gynecologic care and diagnosis of sexually transmitted diseases were tested for Chlamydia trachomatis genital infections. The bimonthly variation in incidence was statistically significant, with a significant peak in the months of August and September of 10.70%, compared with the yearly average of 8.74%. Because the pattern of incidence of chlamydia in university women is seasonal, those concerned with healthcare should increase their efforts during the third quarter to identify infected individuals and to provide preventive programs.

Carcinoma of the trachea: a hidden tumor.

Seventy-five percent or more of the tracheal lumen may be compressed before any signs or symptoms are evident. Typically, chest x-rays are normal. CT scanning is the best radiologic procedure; bronchoscopy is also valuable.

Methanol intoxication. Case report.

A 46-year-old male presented to the emergency room seven hours after consuming a large container of sterno. He could not see and complained of abdominal and back pain. He was tachypneic, tachycardic, hypertensive and hypothermic. Laboratory results were significant for a severe metabolic acidosis, a serum osmolality of 465 and serum methanol level of 493 mg/dl. Aggressive treatment included ethanol drip, bicarbonate and hemodialysis. He survived and regained his eyesight in spite of this degree of elevation of the serum methanol level. The literature does not reveal a similar report.

Methanol intoxication. How to help patients who have been exposed to toxic solvents.

Methanol intoxication can be a challenge, in part because it is relatively uncommon but also because of the pharmacokinetics involved. A patient may not experience symptoms and thus may not present for treatment for several hours, or even a day or two, after exposure to the toxic substance. Yet, the interval between ingestion and treatment is one of the most important factors in determining patient outcome. Typical symptoms of methanol intoxication include lethargy, vertigo, vomiting, blurred vision, and decreased visual acuity. Treatment focuses on prevention of methanol conversion to its toxic metabolites, correction of metabolic acidosis, and elimination of the toxic substances from the system. Ethanol and bicarbonate administration and hemodialysis have been effective.

Lobular carcinoma in situ: what clinicians need to know.

The essential point is that LCIS cells are not likely to progress to invasive cancer. Rather, they represent breast tissue that is predisposed to cancer. Management thus emphasizes close follow-up.

Influence of longitudinal primary care training on medical students' specialty choices.

BACKGROUND: At the University of South Florida College of Medicine, a program designed to give students four years of primary care training began in 1983. As of 1992, six classes that included program participants had graduated. The present study examined the effect of the program on the participants' choices of specialty by comparing their choices with those of other graduates. METHOD: Each year program volunteers were solicited from a class size of about 96 freshmen. Of the 201 volunteers from the classes of 1987-1992, 93 were randomly selected to participate in the program. The participants received primary care education one half-day per week in a community-based clinical setting. The specialty choices of the 543 graduates from 1987-1992 were determined from the National Resident Matching Program and were divided into primary care (family practice, internal medicine, pediatrics); surgery, obstetrics-gynecology, and psychiatry; and other (high-technology specialties). Comparisons were made (1) between volunteers and nonvolunteers and (2) between volunteers who were participants and those who were not. The Z-test was used, with alpha set at .01. RESULTS: Significantly more volunteers--with no difference between participants and nonparticipants--matched with primary care specialties, and more volunteers were women. Significantly more nonvolunteers matched with high-technology specialties--again, no difference between participants and nonparticipants. CONCLUSION: The program did not seem to influence the students' specialty choices, because students interested in participating--regardless of whether they actually participated--were more likely to match with primary care specialties and were more likely to be women.

Validity of immunization documentation presented to a student health program.

BACKGROUND: Unavoidable exposure to disease and to patients susceptible and vulnerable to disease warrants that students entering medical school be immunized against many of the illnesses for which vaccines are available. The validity of immunization records presented at the time of registration, however, is largely dependent on the provision of accurate and reliable documentation by the student. METHODS: We evaluated for authenticity the immunization and tuberculin testing records of 85 students entering medical school in 1990. Five levels of valid documentation were defined, and the information on each record was reviewed accordingly. RESULTS: Only 43% of the records were original documents or laboratory reports of antibody titers, and 7.5% were not date-specific. We found that 8% to 20% of the forms were missing physician and/or student signatures, and 12% to 19% of the forms did not have health care provider addresses. CONCLUSIONS: Even though medical student preventive health programs may have strict requirements, there may be substantial deficiencies in the quality of the documentation provided by the students. Such deficiencies undermine the purpose of these programs.

Cancer screening. Knowledge, recommendations, and practices of physicians.

BACKGROUND: Americans visit their primary care physicians several times a year. These visits provide physicians with many opportunities to reduce cancer risk in their patients by recommending periodic cancer screening. There is evidence of noncompliance among primary care physicians and their patients with regard to periodic cancer screening. Barriers to screening may be perceived by physicians and patients. RESULTS: The authors found that when physicians recommended cancer screening tests, the compliance among patients was relatively high. CONCLUSION: Primary care physicians can take the opportunity to recommend cancer screening tests during routine patient visits, and this strategy may well increase cancer screening rates in the population.

The disclosure of the diagnosis of cancer.

In summary, the consensus today is that full disclosure of the diagnosis of cancer to competent individuals (including children) is morally, ethically, legally, and therapeutically the appropriate policy. Unfortunately, this task is one that most physicians still find awkward, in part because of the continued de-emphasis of "soft" clinical skills in the medical education. Thus, doctors have little opportunity to address their own beliefs and emotions. By being cognizant of clinician unease and using well-described communication skills, however, disclosure can be satisfactorily accomplished. As American health care becomes increasingly ambulatory in nature, primary care physicians will have even more need to hone this skill.

The dieffenbachia plant. Case history.

When ingested, the common house plant dieffenbachia can lead to significant toxicity and possibly death if timely medical attention is not forthcoming following initial exposure. The deleterious effects should not be overlooked especially when children are involved who, naturally curious, may bite into this innocuous looking plant. Although the patient in this case was a type II diabetic on insulin, neither hypo- nor hyperglycemia developed. There was no other significant electrolyte imbalance despite the acute stressor placed on him.

Reverse targeting in a media-promoted breast cancer screening project.

BACKGROUND: The American Cancer Society has sponsored community-based, low-cost, Breast Cancer Detection Awareness Projects throughout the United States. The authors hypothesized that these projects tend to exclude minorities and women of lower socioeconomic status--groups with a higher incidence of late-stage disease. METHODS: A cross-sectional survey was performed of participants in the 1990 Breast Screening Project in Tampa, Florida. The demographic profile of participants was compared with that predicted by 1990 census data. RESULTS: There were 13,920 women who called phone banks for additional information. Of these, 13,215 were deemed eligible and 6640 completed mammographic screening. Forty percent of participants were having mammography for the first time. Comparisons with census data indicated that elderly people, members of minority groups, and women of lower educational levels were underrepresented. CONCLUSIONS: The results of this study support the concept that "reverse targeting" occurs with these breast cancer screening projects, and recommendations for recruiting underrepresented groups are given.

Cancer in socioeconomically disadvantaged populations.

This article presents a summary of the health status of the disadvantaged populations in the United States, with specific regard to the incidence, treatment, and mortality of cancer. It begins with an historical overview of health care for the poor in this country, and continues with an explanation of the risk factors prevalent, if not inherent, in the life-style associated with low socioeconomic status, such as poor diet, cigarette smoking, and ignorance of preventive health measures and screening techniques. It includes a discussion of the different types that are overrepresented in this population and of the barriers to preventive care and treatment that still exist. The most important of these is decreased access to continuous medical care because of a lack of health insurance and an overdependence on emergency room treatment for all health care. The final section reviews solutions that have been preferred by physicians, nurses, lawmakers, public health workers, and community advocates for the poor. The most important parts of the solution are patient education for preventive health care, disease warning signs, and screening techniques and an overhaul of the present system of providing health care to ensure equal access and treatment for all members of the society.

Matriculants' compliance with a required preventive health program.

Several organizations have made recommendations about medical students' health. To determine the University of South Florida College of Medicine's concurrence with published guidelines, a prospective analytic study of the 1990 entering class was carried out, using the 1989 class as a control. Enforcement measures not present in 1989 were initiated in 1990. The requirements for the 1990 matriculants were a history and physical examination; tuberculin testing; immunizations to rubella, rubeola, tetanus-diphtheria, and hepatitis B; status of immunity to chickenpox; and proof of health insurance. The results showed that in 1990 expensive requirements had the lowest rates of compliance, and inexpensive ones, the highest rates of compliance. Comparing 1990 with 1989 showed that the enforcement measures significantly improved compliance for expensive requirements, and for requirements that obligated a student to incur a fee because they needed to be updated. The authors conclude that cost is a major deterrent to compliance and that, in order to improve compliance, medical schools must either implement effective enforcement measures or transfer the cost from the student to the institution.