Little Leaguer's shoulder.

A case of Little Leaguer's shoulder in a skeletally immature patient is described with a review of the English literature. This entity manifests as widening of the proximal humeral physis and is well known to our orthopedic colleagues. To our knowledge, however, there is little in the current radiologic literature describing Little Leaguer's shoulder. We describe such a case.

Patterns of occult bleeding in asymptomatic colorectal cancer.

The assumption that asymptomatic colorectal cancers bleed provides the rationale for widespread stool screening. The authors studied 12 patients with unoperated colorectal cancer but without colorectal symptoms and six healthy volunteers as laboratory controls. All stools were collected for 2 weeks and analyzed by the HemoQuant and Hemoccult tests. In controls, the mean HemoQuant value was 0.7 mg hemoglobin (Hb)/g stool (range, 0.1-1.8) and all stools were Hemoccult-negative. In cancer patients, the mean HemoQuant was 3.3 mg Hb/g (range, 0.3-13.2); stools were within the normal HemoQuant range (less than 2 mg Hb/g) in 38% and negative by Hemoccult in 70%. The mean cancer detection rate testing a single stool per patient was 57% for HemoQuant and 25% for Hemoccult (P less than 0.001). The detection rate rose testing multiple stools and was maximal with five stools at 83% for HemoQuant compared to 31% for Hemoccult (P less than 0.001). The authors conclude that fecal blood levels are commonly normal with asymptomatic colorectal cancer. Although higher with HemoQuant than Hemoccult, cancer detection rates by fecal blood testing appear to be lower than previously reported.

Business values and quality in psychiatric hospital treatment.

The last decade has seen an enormous increase in the use of business techniques in the ownership and operation of psychiatric hospitals. Many physicians have reacted negatively to these developments and have raised many concerns about their impact on patient care. However, commercialism in hospitals is not new. Certain key business values, including attention to a guiding mission statement, the needs of consumers, accountability, and marketing, have a positive impact on the quality of milieu treatment.

Whipple's disease: clinical, biochemical, and histopathologic features and assessment of treatment in 29 patients.

Whipple's disease is a chronic systemic illness, the optimal treatment of which remains poorly defined. In our analysis of a 30-year, 29-patient experience with Whipple's disease at the Mayo Clinic, the frequent initial manifestations of diarrhea, weight loss, arthritis, and lymphadenopathy correlated with findings reported previously by other investigators. Antibiotic therapy yielded rapid symptomatic and biochemical improvement, and histologic changes in the small bowel occurred subsequently. Despite antimicrobial therapy, relapses in patients with Whipple's disease are common, and the central nervous system is considered the most serious site of involvement for recurrence. Administration of an antibiotic agent that is able to cross the blood-brain barrier may be more important in preventing relapse than prolonged duration of initial antimicrobial therapy.

Influence of aspirin and ethanol on fecal blood levels as determined by using the HemoQuant assay.

We sought to determine the short-term effects of use of aspirin and ethanol on fecal occult blood levels measured with the HemoQuant assay. A factorial design was used to study 68 healthy volunteers randomized to receive various doses of aspirin, ethanol, or a combination of both for either 1 or 3 days. Fecal hemoglobin concentrations were measured before and after drug ingestions. Moderate quantities of ethanol (300 ml of 5% or 30 ml of 50% three times nightly) did not cause significant fecal blood elevation unless aspirin was administered concomitantly (P = 0.05). High-dose aspirin alone, 975 mg three times daily, induced abnormal blood loss (P less than 0.01). The highest HemoQuant levels were usually noted after concomitant administration of aspirin and ethanol at maximal doses for 3 days (P less than 0.005), some HemoQuant levels approaching 5 times the normal value. We conclude that, in a short-term analysis, social consumption of ethanol is unlikely to interfere with fecal blood testing but therapeutic doses of aspirin will.

Double lumen esophagus: presentation of esophagogastric fistula, a rare complication of fundoplication.

A double lumen of the distal esophagus, a presentation of an esophagogastric fistula, was found in a patient who previously had an esophageal ulcer following a Nissen fundoplication. Only one other patient in our endoscopic experience of 24 years and 37,808 endoscopies has had this complication. Another patient was found to have an esophagogastric fistula, but it was associated with carcinoma. By contrast, in the 490 patients who had a Nissen fundoplication performed from 1960 to 1983, 23 (4.7%) developed an endoscopically proven esophageal ulcer. Therefore, although a double-lumen esophagus is a rare complication after a Nissen fundoplication, ulceration uncomplicated by an esophagogastric fistula is more common. Presenting symptoms of an esophagogastric fistula may be variable, but our patient, as well as two previous case reports, had dysphagia. The diagnosis is suggested radiologically and established endoscopically.

Vertebral body osteomyelitis: spectrum and natural history. A retrospective analysis of 37 cases.

There has been a definite change in the natural history of vertebral osteomyelitis. At the turn of the century the disease was most often seen in younger people, accompanied by a high incidence of abscess formation and associated with a high mortality rate. Today the disease is more commonly seen in the older age groups and is only occasionally characterized by abscess formation. In addition it tends to be of a lower grade inflammatory reaction and has a better prognosis. A urinary tract infection is a common pre-existing condition. Diagnosis may be difficult particularly before the onset of destructive changes radiologically at 8 to 12 weeks. Biopsy by either open or closed methods might be necessary to establishe the diagnosis and isolate the causative organism which is usually Staphylococcus aureus. Epidural infection is the most devastating complication, particularly if neglected. The duration of treatment is determined by following the clinical symptoms, sedimentation rate, temperature curve and interval radiological changes. The prognosis is good and most patients will recover within one year.