Industrial hypertension program in a rural state. Efficacy and cost effectiveness.

A program was designed to evaluate the efficacy and cost of detecting and treating hypertension in an industrial population of a rural state. Original screening and evaluation was initiated by a trained blood-pressure technician team, but initiation of therapy was the responsibility of the private physician. Follow-up data were obtained at one year by rescreening in 83% and by telephone contact in 91% of the original hypertensive patients. Eighty-three percent of those patients with moderate or severe hypertension complied with physician visits. The condition of 60% of the treated patients was controlled, and the condition of 74% was improved. The total cost per patient treated for one year was 250 dollars; per patient with controlled hypertension, 446 dollars; and per patient with controlled or improved hypertension, $362.     

Staphylococcus aureus endocarditis. Combined therapy with vancomycin and rifampin.

Two children with persistent bacteremia and endocarditis due to Staphylococcus aureus failed to respond to vancomycin therapy, even though serum levels greatly exceeded the inhibitory concentrations. The Staphylococcus from one patient was resistant to methicillin; the other patient had a penicillin hypersensitivity. There was a wide disparity between the minimum inhibitory and the minimum bactericidal concentrations of vancomycin. Striking clinical and laboratory evidence of improvement was demonstrated with the addition of rifampin therapy.     

An obstructed death and medical ethics.

In this case analysis deception or lying to a dying patient is discussed within the context of different relationships: the relationship between the patient and her family doctor, the relationship between the patient and the surgeon and the relationship between the patient and her family. It is suggested that the principle of veracity is not only a core feature in the patient-doctor relationship but is also fundamentally connected with the basic element of trust between the patient and doctor. The surgeon, in deceiving the patient, even at the request of her husband, betrayed her trust in violating the principle of veracity. The primary responsibility of the surgeon was towards his patient rather than her family. In lying to his patient the surgeon failed to give Mrs Fasper something she needed most: respect for her as a person.     

Essential (hereditary or senile) tremor.

Sixteen cases (eight in males and eight in females) of essential (hereditary or senile) tremor were collected over a two-year period. Ten patients had near relatives with a similar disorder. All but one patient had a tremor of the upper limbs which was absent when the arms were at rest, but which appeared on movement, and was made worse by emotion. The severity of the tremor varied considerably from patient to patient, and often was temporarily lessened by alcohol. The tremor involved the head and neck in six subjects and the legs in two. One subject has associated neurological abnormalities probably due to cerebral arteriosclerosis. Otherwise no neurological abnormality except tremor was present in any patient. No patient showed evidences of Parkinsonism. To the time of collection of the series the tremor had been present for periods of between one and 62 years. Many patients with essential tremor are not severely enough affected to warrant therapy. Propranolol, a beta-adrenergic blocking agent, appears to reduce the tremor in at least some patients who need treatment.     

The limits of informed consent.

The patient, a 59-year-old man, was referred to a psychiatric hospital with what appeared initially to be the signs and symptoms of mental disorder. In hospital a lesion of the brain was diagnosed and surgery was proposed to relieve the condition. The patient, however, during this and subsequent admissions to hospital, refused operation. His refusal to consent was regarded as valid as he seemed to have good insight into his condition. Finally, under section 26 of the Mental Health Act, he was treated surgically. Unfortunately the patient died six weeks later of intracranial haemorrhage. Three comments are made on this case - two by psychiatrists, Dr K Davison and Dr Ashley Robin, the other by a professor of Christian ethics, Professor F C Blackie. Both psychiatrists argue that when a patient's mind is affected by mental or organic illness to the degree that 'he cannot bring a rational and conscious mind' to the question of his treatment then the doctor, in consultation with the relatives, making clear to them the likely course of events if an operation is not performed, must take whatever is the proper course of action, in this case surgery. In this view, such an operation performed immediately the diagnosis was confirmed might not have been so complicated. Professor Blackie, commending 'the attempt to regard the patient as a responsible human being' with a 'moral right to be consulted on all aspects of treatment', questions in this patient the limits to which the appeal to reason was carried. He concludes that 'in this situation the advice and consent of the family must weigh more heavily than the statements of the patient'.     

Gram-negative sepsis with acute renal failure. Occurrence from acute glomerulonephritis.

Acute intrinsic renal failure occurred in an adult patient with Escherichia coli septicemia. The clinical course did not include any of the circumstances usually present when acute renal failure complicates Gram-negative sepsis. A renal biopsy showed acute proliferative glomerulonephritis. There was no evidence to support other known causes of acute parenchymal renal failure, such as poststreptococcal glomerulonephritis, subacute bacterial endocarditis, or vasculitis. The patient recovered completely with antibiotic therapy, and renal function returned to normal within two weeks. An immunologic mechanism involving E coli was considered responsible for the acute renal failure.     

Hematology.

Senior medical residents were used to extend psychiatric coverage in a busy hospital emergency room. Their service was supported by the backup consultation of senior psychiatric physicians. The medical residents worked in conjunction with psychiatric residents to provide 24-hour daily emergency psychiatric service to more than 350 patients during a 12-month period. There were no significant differences in the demographic composition of the patient population seen or in the disposition of individual patients made between the medical and psychiatric residents. The hospital was able to expand its psychiatric service in the emergency room without major increases in cost. The medical residents benefited by experiencing a more diversified patient care training program, and they earned a modest supplement to their houser officer salary.     

Therapeutic experience with netilmicin.

Netilmicin, a new aminoglycoside antibiotic, was used to treat 19 patients with urinary tract infection and 5 with systemic infection. The causal organisms were Escherichia coli (in 2), Klebsiella pneumoniae (in 4), Serratia marcescens (in 12) and Pseudomonas aeruginosa (in 7); 1 patient was infected with two of these organisms. All the isolates of causal organisms except one of Serratia were initially sensitive to netilmicin but many were resistant to other aminoglycosides. Sixteen of the urinary tract infections responded to netilmicin therapy, although relapse occurred in three patients. Two of the three patients with musculoskeletal infection responded to combined therapy with surgery and netilmicin; the other patient responded to the same regimen but with carbenicillin added. Netilmicin cured pneumonia in one patient but failed in the other patient with pneumonia, who had leukemia. Superinfection occurred in five patients with urinary tract infection. Adverse reactions to netilmicin were minor. Netilmicin may prove to be a useful agent, particularly for infections due to multiresistant Klebsiella or Serratia, or when prolonged aminoglycoside therapy is required.     

先天性簇绒肠病EpCAM基因复合杂合突变（c.491+1G>A；c.352_353ins CACC）1例报告

患儿男,1月龄,因“反复腹泻20+ d,吐奶4 d”入院。患儿生后第8天开始出现反复顽固性腹泻,伴腹胀、呕吐、脱水、酸中毒、营养不良,家族中多例消化系统恶性肿瘤患者。基因检测发现人上皮黏附因子（epithelial cell adhesion molecule, EpCAM）基因复合杂合突变（c.491+1G>A;c.352_353ins CACC）,确诊为先天性簇绒肠病。予部分肠外营养支持,患儿腹泻好转,但加奶困难,奶量增加即腹胀、呕吐。住院后期出现反复发热,最终家属签字出院。出院后仍有腹泻、吐奶,出院4周患儿体质量下降约1 kg,最终死亡。     

Chronic suppurative lung disease with associated vasculitis.

We report a patient with chronic bronchiectasis who developed systemic vasculitis. The patient was initially treated with immunosuppression; however, the addition of antibiotic therapy improved control of her vasculitis and the need for immunosuppression was reduced. Chronic bronchial suppuration may have an aetiological role in the pathogenesis of this condition.     

Electrocardiographic changes following a cardiac stab wound. Case report and review of the literature.

A patient is described who sustained a cardiac stab wound which was associated with ECG evidence of a full thickness myocardial infarction. Subsequent investigation showed a localized area of dyskinesia on left ventricular angiography, but normal thallium myocardial perfusion and normal anatomy on coronary angiography. The patient was managed conservatively and made a complete and uneventful recovery. It is concluded that extensive ECG changes following a cardiac stab wound need not be associated with major coronary artery damage.     

The diabetic day-care unit. II. Comparison of patients and costs of initiating insulin therapy in the unit and a hospital.

Fifteen patients began insulin treatment in a diabetic day-care unit and 14 patients began insulin treatment in hospital. The cost per patient of initiating insulin treatment in hospital was nine times the cost in a day-care program. In general, the disease of patients with juvenile-onset diabetes was initially under poorer control in those admitted to hospital than in those in the day-care program. However, the day-care juvenile with disease under poorest control was comparable to the most severely affected patient admitted to hospital. No major differences in the improvements in control achieved by the two programs were found.     

Limits of confidentiality.

A patient is described, a woman of 60, who at that age was diagnosed as having Huntington's chorea, a genetic disease which is transmitted as an autosomal dominant. She had one daughter, who was married and lived abroad. The patient's mother and maternal aunt, it emerged during the consultations, had had the disease, and shortly after the diagnosis had been made the patient's sister was admitted to hospital with a repiratory condition, and in the course of treatment Huntington's chorea was diagnosed in her also. She had one daughter. Throughout, the problem was not only that of treating the patient herself, but the situation of all those of the family affected in any way. The patient's husband had not known of her medical history at the time of the marriage. At no time had the daughter been told. The discussion, in which seven doctors, a moral philosopher, and a social worker took part, centered on the basic issue of confidentiality in the case of a disease, from which would stem problems for the affected family through several generations. All were agreed that in these circumstances those affected must be told, but differed as to who should make some of the subsequent decisions. Some thought that having told of the diagnosis and its implications, the doctor should leave further decisions to those concerned; others that in a disease such as Huntington's chorea one is looking at part of a whole chain of genetic material, and, although the individual patient or potential patient is of course important, he or she must be seen in the genetic setting of the community. The participants also considered the psychological.     

Paternalism modernised.

The practice of paternalism has changed along with developments in medicine, philosophy, law, sociology and psychology. Physicians have learned that a patient's values are a factor in determining what is best for that patient. Modern paternalism continues to be guided by the principle that the physician decides what is best for the patient and pursues that course of action, taking into account the values and interests of the patient. In the autonomy model of the doctor-patient relationship, patient values are decisive. In the paternalistic model, they are but one among several factors the physician must consider in making a medical decision. Although difficult to practise because of limitations in empathising with another person, modern paternalism remains a way to achieve maximum patient benefit.     

Relative lactose intolerance. A clinical study of tube-fed patients.

A relative intolerance of lactose was demonstrated in 14 of 16 patients receiving nasogastric tube feedings following surgery for head or neck carcinoma. Two liquid diets differing only in the presence or absence of lactose, were administered for eight to 20 days per patient in a double-blind crossover study. Increased stool frequency, decreased stool consistency, and more frequent flatulence, borborygmi, and distention were found with the lactose diet, although classic lactose intolerance (plasma glucose rise of less than 26 mg/dl) was indicated in only two patients. Differences between amounts and times of peak rise following the glucose tolerance test and lactose tolerance test for each patient indicated the advisability of locating patients on a continuum of ability to hydrolyze lactose. The results indicate that lactose should be reduced or eliminated from tube-feeding diets to improve patient tolerance and comfort and to reduce diarrhea.     

Abetalipoproteinaemia. A case report with pathological studies.

The clinical and pathological features of a case of abetalipoproteinaemia in a 38-year-old patient are described in detail. A feature not previously recorded was a marked reduction in the velocity of ocular horizontal saccadic movements. Pathological studies revealed an active chronic demyelinating process. The patient showed no response to large doses of vitamin E. The rationale for this therapy, and the possible reasons for its failure are discussed.     

Anorexia nervosa, liquorice and hypokalaemic myopathy.

A patient with a past history of anorexia nervosa developed a hypokalaemic myopathy following a ''flu-like illness. Although she was apparently in remission from anorexia nervosa, the diet was found to be markedly abnormal with an excessive ingestion of liquorice and a low potassium salt intake. The clinical features and investigations, including muscle biopsy, are described. The patient is compared, with 2 reported cases of liquorice-induced myopathy, and the relationship between anorexia nervosa, liquorice and hypokalaemic myopathy is discussed.     

Hyperthyroidism due to functioning metastatic thyroid carcinoma. Precipitation of thyroid storm with therapeutic radioactive iodine.

Two patients had hyperthyroidism secondary to functioning metastatic follicular thyroid carcinoma. Failure to control the thyrotoxic state with antithyroid drugs in one patient prior to treatment with radioactive iodine led to exacerbation of the thyrotoxicosis with thyroid storm and death. A second patient, in whom a euthyroid state was induced before radioactive iodine therapy, had a benign posttreatment course. Radioactive iodine therapy of functioning metastatic thyroid carcinoma should be administered with caution and only after adequate preparation of the elderly patient with cardiovascular disease.     

Hypercalcaemia and phaeochromocytoma.

A patient with a phaeochromocytoma associated with hypercalcemia is described. The hypercalcaemia was corrected by removal of the phaeochromocytoma. Parathyroid hormone-like peptide was isolated from the tumour suggesting that ectopic parathyroid hormone production from the phaeochromocytoma was the explanation of the hypercalcaemia.     

Neurofibrosarcoma in Von Recklinghausen's disease presenting with hypochromic anaemia.

A patient with Von Recklinghausen''s disease who developed a retroperitoneal neurofibrosarcoma is described. The presenting clinical picture was one of hypochromic anaemia with a large mass palpable in the left hypochondrium. At operation the tumour was found to be invading the small intestine with resultant blood loss. The patient had presented 21 years before with unexplained severe iron deficiency anaemia.