A 47-year-old man with eruptions on his trunk

A 47-year-old white male came to the hospital emergency department complaining of chest pain. At admission, it was noted that the patient had numerous lesions on his buttocks, abdomen, back, and all extremities. These lesions had been there for approximately 5 months--they developed after he discontinued his cholesterol medication due to lapsed insurance coverage. He had a similar eruption when he went off cholesterol medication on another occasion. The patient's medical history included type 2 diabetes mellitus, hypertension, coronary artery disease, and hyperlipidemia. He has had multiple heart catheterizations with stent placement, most recently 2 years ago. His mother also had diabetes mellitus, and she died at age 58 from a myocardial infarction. On examination, his lesions were painless and nonpruritic. He had numerous yellow papules on his buttocks, abdomen, back, and upper and lower extremities. He had no lesions on his face. The rest of the physical exam showed no abnormal results. What is your diagnosis? What laboratory tests should be done to help make the diagnosis?     

Just a sore throat?

A man, 43 years of age, presents to his general practitioner with a 6 day history of sore throat. There are no other symptoms of an upper respiratory tract infection. In passing, the patient mentions that 6 days ago he experienced an episode of exertional chest pain. On further questioning it is found the chest pain was central with no radiation, it lasted 30 minutes, resolved spontaneously and was associated with nausea. He did not seek medical assessment at the time and has no cardiac history. He takes no regular medication and has no allergies. He is an exsmoker with a 15 pack-year history (he quit 7 years ago) but has no other known cardiac risk factors. He does not drink alcohol or take illicit drugs. On examination, he appears well built with a body mass index of 27. He is not in distress apart from a moderate sore throat. He is afebrile. His heart rate is 66 bpm, regular and his blood pressure is 122/80 mmHg. His tonsils and uvula are neither inflamed nor swollen. He has no cervical lymphadenopathy. His lungs are clear on auscultation and his heart sounds are dual with no murmur. His electrocardiogram is shown in Figure 1.     

Transsexualism in Vietnam

The case described is that of a man raised in the Vietnamese peasant countryside who clearly fits the transsexual syndrome. On physical examination he appears to be a normal male, yet he insists that he is a female. He dresses as a woman and is able to successfully pass in society. He relates that he felt he was a female from earliest childhood. He prefers nonhomosexual men, denies any heterosexual experience, and has an all-consuming desire for the sexual transformation operation. This paper focuses on the social aspect of transsexualism and the manner a society, particularly the Vietnamese, may handle transsexual behavior. These ways can be seen to fall into a continuum. On one end, sexual role reversal is institutionalized and transsexual-like behavior is carried on according to a prescribed cultural pattern. The Vietnamese hermaphroditic witch could be included in this category. In the middle of the continuum, the idiosyncratic transsexual is provided an acceptable cultural role, and he therefore should be visible when he occurs. The Vietnamese young person who cross-dresses could perhaps be in this category. On the other extreme, the transsexual role is not conceivable or, at best, is very marginal. Here, the transsexual remains hidden in the general culture and can only be detected, as the person described in this paper, by accident.     

Reflections on prevention at the macro-level: An interview with George Albee

George Albee enjoys a wide reputation as a founder of the prevention movement in the field of Psychopathology, having devoted his professional career to the prevention of mental and emotional disabilities. Dr. Albee has served as President of the American Psychological Association and Director of the President's Commission on Mental Health Task Force on Prevention. His early prevention formula has been the prototype for many explanations of prevention that have followed. He is Professor of Psychology at the University of Vermont, where I interviewed him in April, 1989 (with a follow-up in 1990).This article appears as a chapter in the book: Pransky, J. (1991).A Pound of Prevention...: The Critical Need for the '90's. Springfield, MO: Burrell Foundation; and Burlington, VT: Waterfront Books.     

Night blindness in a teenager with cystic fibrosis

This article describes the case of a 16-year-old boy with cystic fibrosis who presented with difficulty seeing in the dark. He had a history of bowel surgery at birth, and he developed cystic fibrosis liver disease and osteopenia during his teenage years. He always had good lung function. When his serum vitamin A level was checked, it was undetectable in sample. He was diagnosed with night blindness and commenced on high-dose vitamin A. His symptoms resolved within 3 days. However, it took over 1 year for his vitamin A level to return to normal. This case emphasizes the importance of monitoring vitamin levels in cystic fibrosis to detect deficiency and prevent long-term consequences, and it highlights the challenges encountered during the course of night blindness treatment.     

Diabetes: Relentless Progress Against a Relentless Disease

A 60-year-old man was seen for evaluation of intermittent palpitation. For the preceding three weeks he had noted periods of rapid heartbeat that occurred every few days and lasted most of the day. He had noticed it more often when he was at rest than during activity. He had not had chest pain, dyspnea, or other symptoms.

There was no history of heart disease or cardiac symptoms. However, during the preceding Ave years his blood pressure had ranged from 150 to 160 mm Hg systolic and from 85 to 90 mm Hg diastolic, and his total serum cholesterol had ranged from 215 to 235 mg/dL. He was not a smoker.

The patient was slightly obese and appeared to be healthy and in no acute distress. His pulse was 147 beats per minute and regular, blood pressure was 165/95 mm Hg, respirations were 18 per minute, and temperature was 37.1°C. His skin was warm and dry. The thyroid was impalpable. The jugular venous pressure was normal, the lungs were clear to percussion and auscultation, and the cardiac examination was unremarkable except for tachycardia. The remainder of the examination was also unremarkable.     

Acute copper sulfate poisoning resulting from dermal absorption

We report a Korean worker who experienced dermal exposure to a hot copper sulfate solution at his workplace and developed severe acute copper sulfate poisoning. A 53‐year‐old male worker, who was employed in a lead smelter for 5 years, slipped, and his right lower leg entered a copper sulfate solution, leading to severe burns of the right lower leg. Two days later, he developed severe intravascular hemolysis with methemoglobinemia. He also suffered from acute kidney injury, had an asymptomatic cerebral ischemic stroke, and melena due to multiple shallow gastric ulcers. His serum copper level was mildly elevated (153.6 μg/dL, reference: 64.0‐134 μg/dL). He was transfused with red blood cell concentrate and supported by hemodialysis. After 13 sessions of hemodialysis and several blood transfusions, he completely recovered. Most previously reported incidents of severe acute copper sulfate poisoning were from accidental or suicidal oral intake. There are few previous reports of systemic copper sulfate toxicity following exposure through burned skin.

     

Human rabies--Québec, Canada, 2000

On September 22, 2000, a 9-year-old boy awoke with a fever and complained of pain in his upper left arm. The pain persisted, and he developed insomnia and tremors in his arm and hand. He was admitted to a local hospital on September 27. That evening, he had mild dysphagia, pruritus of his upper chest and back, and a transient macular rash. On September 28, he developed tremors and myoclonic jerks in both arms, had become agitated, and had hydrophobia, aerophobia, dysarthria, and visual hallucinations. The next day hypersalivation was observed and the tremors and myoclonus had spread to his lower extremities. He became very anxious, indicated that he was suffocating, and underwent endotracheal intubation. A diagnosis of rabies was considered and he was transferred to a children's hospital. Laboratory findings were normal except a mildly elevated cerebral spinal fluid protein. An electroencephalogram form indicated no epileptiform activity. Head magnetic resonance imaging was normal. On September 29, the results of the rabies tests were positive, and rabies immune globulin and vaccine were administered to the patient. His neurologic and hemodynamic status deteriorated, and he died on October 6.     

Wendell H. Griffith (1895-1968). Biographical sketch

Wendell Griffith made an indelible impression on his students, his colleagues and the broad field of the nutrition sciences. He was the prototype of the physiological chemist studying intricate problems of intermediary metabolism in the whole animal or human body. His early scientific reports on choline and amino acid metabolism set a high standard for intellectual precision and literary clarity. Dr. Griffith's last research paper was entitled "The Present Knowledge of Methyl Groups in Nutrition" and appeared in Nutrition Reviews in 1968. In this paper he reviews the substance of figure 2, which depicts the advancement in knowledge of choline metabolism, methyl biosynthesis, and transmethylation during his career. It is fortunate that Dr. Griffith was able to witness many of the developments in a field that he had pioneered. If he were alive today, he would be delighted to see how much further this field has moved. Wendell Griffith was a complete man. He combined the traits of high intelligence with a selfless patience and kindness, uncommon in productive scientists. His lucid and absorbing lectures were a joy to his students. Furthermore, he was a mentor with warmth and charm in his relationships to his graduate students and young faculty members and was a superb role model for them. After they left his department he was most supportive. Part of his own rejuvenation, I am sure, occurred in the out-of-doors where he loved to garden, hike and fish. Griff did not grow old, or it seemed he did not. He died at the age of 72 in Baltimore from a brain tumor that was of relatively sudden onset, and is buried in Oak Hill cemetery in Kirkwood, MO, a suburb of St. Louis. He enriched the lives of all of us who had the good fortune to know him. Moreover, his work lives on to stimulate the minds of all serious students of biochemistry and nutrition.     

Pediatrician says clinic fired him because he had HIV

Dr. Thomas "Terry" Jefferson has filed a suit charging he was fired by a clinic he co-founded because he was HIV-positive. Additionally, his case raises the issue of whether someone who is a principal in a business can also be considered an employee, and therefore be subject to Federal anti-discrimination provisions. Jefferson, a pediatrician, was HIV-positive for 2 years before taking a medical leave of absence. He had separated from his wife and sought treatment for depression. After 2 months, he was making plans to return to work when he was told he was terminated. Around that time, Jefferson told his children he had HIV. His attorney said they may have told their mother, who told a partner physician. Jefferson is seeking reinstatement, lost wages, insurance coverage, other damages, and injunctive relief. Contact information is provided.     

Mt. St. Anonymous the adolescent living-related donor

Seventeen-year-old David is a perfect organ match for his younger brother, Ken, who has kidney failure. David understands that the procedure presents some risk for him and that after surgery he may no longer be able to continue playing football. His idols all have been football players and he now plays on his high school's team. Nevertheless, he wants to donate a kidney to his brother and agrees to being a donor as soon as the option is mentioned. He never displays any ambivalence and says, I want to donate my kidney because then I'll be a hero to my family. This close family - of two parents and five older siblings — strongly supports the seventeen-year-old's decision, especially after an older brother, who was also a perfect organ match, is found medically (anatomically) unsuitable.The parents and two of the older siblings could still be medically acceptable donors: their organs are likely to be better grafts (one haplotype matches) than a non-related cadaveric kidney would be, but less compatible than the perfect organ match (haploidentical) that could be provided by David, the adolescent brother. Studies have shown that in the short run there is little difference in the survivability of organs from different classes of donors. After several years, however, there is a significant difference with perfectly matched kidneys being much less prone to rejection than the less ideally matched organs (1, p. 118).     

环境与疾病理论奠基人——希波克拉底

希波克拉底(Hippocrates, 460-370 BC), 古希腊名医, 西方医学奠基人。他是人类医学历史长河中的“里程碑式人物”, 被认为是历史上第一位流行病学家。他创造了“四体液学说”医学理论, 使人类医学摆脱神学, 迈入自然医学模式; 他辛勤笔耕on Airs, Waters, and Places著作, 奠定了两千多年的流行病学思想基础; 他以高尚的医德为人称道, 其《希波克拉底誓言》传颂至今; 他与门徒集成大作《希波克拉底文集》, 传育了一代代医者。故, 希波克拉底被尊称为“医学之父”。     

Dilated pupils, dry mouth and dizziness - a case study

A man, 44 years of age, presented with a 4 hour history of dizziness, blurred vision, dry mouth and dilated pupils. He was previously well and on no medications and there was no history of recent drug use, head injury or focal neurological symptoms. On questioning, the patient said that he had eaten lupini beans for lunch but that he hadn't had enough time to soak them for long enough before eating them. On examination his Glasgow Coma Score (GCS) was 15/15, heart rate 98 bpm, blood pressure 144/98, temperature 37.8°C and respiratory rate 18 breaths/minute. His skin was warm and dry with dry mucous membranes. His pupils were dilated at 6 mm and were nonreactive. Cardiovascular, respiratory, abdominal and neurological examinations were normal. He was unable to pass urine. Electrocardiogram showed normal sinus rhythm with a rate of 98 bpm.     

Failed bias-by-association lawsuit costs plaintiff $29,000

U.S. District Judge Joe Kendall ruled that the plaintiff's discrimination lawsuit was filed frivolously, and that he had to pay his former employer more than $29,000 for attorney's fees incurred in its defense against the lawsuit. The plaintiff was unable to show that Charter Furniture Rental Inc. was aware of his sexual orientation or his partner's AIDS-related illness. The plaintiff made every effort to conceal his homosexuality. He claimed his live-in partner was just a roommate. The plaintiff missed time at work after his partner's health began to decline in 1995. His firing came soon after his partner's death. He filed a complaint with the Texas Commission on Human Rights, which found no reasonable basis to believe the law had been violated. The employer insisted it had done nothing wrong and did not know about the plaintiff's sexual orientation or his partner's AIDS. Attorney's fees were sought based on the accusation that the plaintiff's attorney failed to perform an adequate pre-filing investigation. The judge ruled that the only basis for the plaintiff's firing had been poor work performance.     

Little heroes in distress

How does a child grow up to be a "real boy" and which messages does he receive from his parents and other adults to become a young man? Focus is on information concerning the physical and mental health of an adolescent male and his desires, fears and sexual experiences. Last but by no means least spotlight is on how adults appreciate and deal with the needs and anxieties of a youngster or "little hero". Particular attention centers on the problem of forcing youngsters into a malehood characterised by fearlessness and an intrepid attitude, by banking on their sex-specific fears of not being rated as "real young boys" because they may be losers in some instances where they are expected to be aggressive or where they experience sorrow and a desire for tenderness. Such demands made on adolescent boys by an inconsiderate environment can have incalculable consequences on their psychosocial potentials and on their physical and mental health and well-being.     

Happiness in childhood

Jean Jacques Rousseau was born in 1712 in Geneva. His mother died within a week of his birth. He began to read books from his father's library at age 6. After a brief period at boarding school and as an apprentice engraver, Rousseau began to read prohibited books, joined a youth gang, and finally, at age 16, became a vagabond. So began a life of teaching, writing, and wandering that by the time of his death in 1778 would mark Rousseau as one of the great thinkers of the modern period.Rousseau'sSocial Contract, published in 1762, is given credit for inspiring the French Revolution. The opening line, Man is born free, but everywhere he is in chains, still echoes powerfully down the centuries. Rousseau'sEmile, also published in 1762 and from which this selection is excerpted, had a similar impact on the world of child rearing and education. Rousseau's command to love childhood, his de-emphasis on intellectual training, and his emphasis on nature and experience set off two centuries of reform. He placed children at the center of their own lives.Emile was burned in Paris and Geneve for its attacks on authority.Today, we think we have learned what we can from Rousseau; perhaps we have listened too closely. But it is too easy for those of us in modern institutions to give glib assurances that we love children and childhood. Rousseau's perspective on what this really means is still needed.Reprinted with permission fromThe Emile of Jean Jacques Rousseau: Selections, edited by William Boyd, pp. 33–37. New York: Teachers College Press, Columbia University, 1962.     

Occupational laryngitis caused by formaldehyde: A case report

Formaldehyde is commonly accepted to be an allergen and irritant. However, specifically diagnosed occupational respiratory diseases caused by formaldehyde are relatively rare. Occupational laryngitis was diagnosed in a 47-year-old dairy foreman. He had been exposed for 9 years to formaldehyde emitted from a milk-packing machine situated underneath his office. His exposure level varied considerably. Under normal process conditions, the measured formaldehyde level was 0.03 mg/m³. The patient was examined by different specialists over 1½ years. It was concluded that that he had psychogenic dysphonia. However, a specific laryngeal provocation test with formaldehyde carried out at the Finnish Institute of Occupational Health was positive. His laryngitis was so serious that he was pensioned. During the 3 years of follow-up his condition gradually worsened. He now reacts especially to tobacco smoke and other air impurities known to contain formaldehyde. © 1996 Wiley-Liss, Inc.     

Health literacy: how visuals can help tell the healthcare story

Herb, a 66-year old general contractor, had a major heart attack five years ago. His doctor performed an emergency coronary angiography to examine the blood vessels and chambers of his heart. After the procedure, Herb's doctor gave him a simple line drawing of the heart and arteries. She then coloured in where each artery was blocked and wrote alongside how much each was occluded. Seeing so clearly what was wrong, Herb readily agreed to participate in a cardiac rehabilitation program and change his diet and exercise habits. He did so well that he was asked to speak with other patients who had just been diagnosed with cardiovascular disease. To Herb's surprise and disappointment, not one of the more than 100 people he spoke with had ever been given a 'heart picture' like his. Herb often hears people say how these types of drawings could have helped them better understand their diagnosis and treatment recommendations.1.     

Uncontrollable Frenzy and a Unique Temporary Insanity Plea

On a bright, sunny April 1859 afternoon in Washington, D.C., a brutal murder occurred in Lafayette Park, directly across from the White House. Ironically, a close friend of President James Buchanan shot and killed his wife's lover. Daniel E. Sickles, a cuckolded U.S. Congressman, attacked and killed Philip Barton Key, the U.S. Attorney for the District of Columbia. Key was one of the eleven children of Francis Scott Key, the author of the poem that became The Star Spangled Banner. At the trial, Sickles' seven lawyers presented an insanity plea claiming that an uncontrollable frenzy created a brainstorm resulting in temporary insanity. In addition, the defense argued that the unwritten law provided immunity to a husband who avenged his honor. Only lay witnesses testified as to Sickles' intense emotional outrage. There was no expert medical witness to support the insanity plea. Prosecutors maintained that the killing was a premeditated murder, or at the very least manslaughter.     

Immunological and detoxication interaction in p,p-DDT fed rabbits

Summary Thirty-one rabbits were immunized against Salmonella or SRBC. These rabbits had an impaired immunological response when they received 200 ppm p,p-DDT in their drinking water during a period of 38 days. The total gamma globulins as reflected by the 7 S fraction were significantly decreased in the p,p-DDT-Salmonella receiving rabbits when compared with the rabbits receiving only Salmonella. This decrease was not statistically significant in the p,p-DDT-SRBC receiving rabbits when compared with the rabbits receiving only SRBC.The antibody titer against Salmonella was significantly decreased in p,p-DDT-Salmonella receiving rabbits when compared with the rabbits receiving only Salmonella. The decrease of the SRBC antibody titer in the p,p-DDT-SRBC receiving rabbits was not statistically significant.The plasma total DDT level differed significantly in the two groups receiving p,p-DDT (p,p-DDT-Salmonella and p,p-DDT-SRBC receiving rabbits). This finding may explain the different degree of impairment of the immunological response, the higher plasma DDT level having a more marked effect. These differences in total DDT plasma level in the two groups of rabbits which received the same amount of p,p-DDT in their drinking water may be considered as a consequence of the concomitant presence of a different kind of foreign antigen in the internal milieu.The bi-directional relationship between a detoxication process and an immunological response is emphasized.This investigation was supported by a grant from the World Health Organization, International Agency for Research on Cancer, Lyon.