Prochlorperazine-induced extrapyramidal effects mimicking meningitis in a child

Certain medications, such as the phenothiazines, may cause side effects that result in neck stiffness and may actually mimic the presentation of meningitis, especially in children. Despite the controversial use of antiemetics, they continue to be used in children with viral gastroenteritis. I describe the case of a child who had a febrile seizure and meningismus during the course of a viral gastroenteritis, not due to meningitis but to the untoward side effect of an antiemetic. Clinicians must be aware that these medications may cause extrapyramidal side effects that may mimic other more serious diseases and lead to unnecessary evaluations; therefore, their use cannot be strongly encouraged. If antiemetics are prescribed, physicians should emphasize possible side effects so that corrective treatment can be initiated promptly.     

Selecting a computer system for a medical practice

Although the risk will always exist that a computer system will be selected that does not adequately meet the needs of a practice, this risk may be minimized when the selection process is done properly. A seven-step approach for selecting an office management system is described, with discussion of major factors to consider and pitfalls to avoid.     

On a wing and a prayer: medical emergencies on board commercial aircraft

Medical emergencies sometimes arise in the isolated and confined environment of a commercial aircraft. Because a physician passenger may be on board in 40% to 90% of all commercial flights, it follows that this physician may be asked to render assistance to an acutely ill passenger. Although data suggest that the incidence of such emergencies is low, the potential for serious events necessitates a degree of familiarity with the nature of emergencies in the air and with the options available to the travelling physician.     

Factitious injury of an extremity: a Munchausen variant

Self-induced injury of one or more of the extremities may represent a distinct variety of Munchausen syndrome. The nature of the injury may be infectious, dermatologic or orthopedic. The mechanism may be secondary gain or another unconscious motivation that causes a craving for attention. In many cases, the underlying psychopathology is personality disorder.     

Implementation of a low titer group O whole blood program for a law enforcement tactical team

The Texas Ranger Special Operations Group (SOG) performs high-risk warrant service and responds to callouts for evolving kinetic situations and special missions as required. These operations may occur many hours from a trauma center. Fresh whole blood (FWB) transfusions may offer a stopgap for those who are critically injured. To make FWB transfusions a viable option, several steps must be implemented. The following lays out how the Texas Ranger SOG will implement and conduct FWB transfusions using low titer group O whole blood. The techniques outlined may be useful for communities that may face critical blood shortage in disasters.     

Sexual relations after a myocardial infarction

After an acute miocardiac infarction, sexual disorders may appear in a high percentage of patients. This article analyzes the problems which can lead to a sexual dysfunction, and presents a series of recommendations so that a nurse may explain these to the patient. If the patient possesses sufficient clear information, he/she will be able to overcome the inconveniences which occur with greater ease and thus be able to lead a fuller, happier life.     

Operational research and cost containment: a general mathematical model of a workstation

To facilitate planning and management, I have derived a mathematical model describing the dynamics of a workstation that receives a mixture of routine and emergency specimens. The model parameters include the maximal specimen-processing rate (to be defined by personnel representatives) and the longest delay allowed for emergency specimens at the workstation. Based on the model, a computer-simulation technique has been developed to maximize the length of time (planned pauses) during which the workstation could be closed without causing undue delay of routine and emergency specimen results. The application of this technique is illustrated with real data, in which more than 50% of the specimens were emergency specimens. Three pauses, constituting 35% of working hours, could be introduced with a negligible impact on the turnaround time of emergency specimens (mean increase = 8 min). The model may also be used to derive, as a function of time of day, the largest extra workload that may be presented to a workstation without creating overwork. The workload could be increased by 45%, provided that all additional specimens arrived before noon.     

Hypothyroidism and depression: a therapeutic challenge

OBJECTIVE: To describe a patient with longstanding depression and hypothyroidism who had marked mood improvement only after triiodothyronine (T3) was added to her thyroxine (T4) replacement therapy. CASE SUMMARY: A 50-year-old white woman had a long history of depression and documented hypothyroidism since 1991. Despite treatment with T4 with dosages up to 0.3 mg/d, she continued to be depressed, have symptoms of hypothyroidism, and have a persistently elevated thyroid-stimulating hormone concentration. Addition of a low dose of T3 to her regimen resulted in significant mood improvement. DISCUSSION: The relationship between hypothyroidism and depression is well known. It is possible that this patient's long history of depression may have been a consequence of inadequately treated hypothyroidism, due either to poor patient compliance or resistance to T4. Nevertheless, her depression responded to addition of a low dose of T3 to her regimen. This case emphasizes the importance of screening depressed patients for hypothyroidism. Her clinical course also suggests that depression related to hypothyroidism may be more responsive to a regimen that includes T3 rather than to replacement with T4 alone. This is consistent with the observation that T3 is superior to T4 as adjuvant therapy in the treatment of unipolar depression. CONCLUSIONS: Depressed patients should be screened for hypothyroidism. In hypothyroid patients, depression may be more responsive to a replacement regimen that includes T3 rather than T4 alone. Therefore, inclusion of T3 in the treatment regimen may be warranted after adequate trial with T4 alone.     

The use of mirtazapine in a patient with chronic pain

Antidepressant drugs that act on serotonin and noradrenergic systems may be analgesic. The newer antidepressant mirtazapine (Remeron) has activity on noradrenergic and serotonergic transmission and is approved for the treatment of a Major Depressive Disorder. This paper describes a case that suggests that mirtazapine may also be useful in the treatment of chronic pain.     

Health care workers' anxieties and fears concerning AIDS: a literature review

Acquired immunodeficiency syndrome (AIDS) is a serious illness and a public health crisis that merits the concern of everyone. Three key features make AIDS difficult to control. The first feature is that the disease is predominantly spread sexually. The second feature is that a period of infectivity may last from months to years, and the infected individual may not be aware that he or she is infected. The last feature is that AIDS also may be spread by percutaneous and perinatal transmission. Whatever success public education may have in changing sexual behavior, it will not be seen for several years, and the number of AIDS cases will continue to grow. The following literature review leads to a prediction that education will have a profound impact on the anxiety connected with providing care for AIDS patients. Education is a powerful tool that can be used by health care workers to change how AIDS is perceived. Health care workers must become aware of their misconceptions, fears, and anxieties about this disease and afflicted individuals.     

Guilt: a crisis within a crisis

Resolution of the crisis created by a catastrophic neurologic event can be obstructed by the patient's or family's feelings of guilt. This article describes the stages of guilt and manifestations that can be assessed by the nurse. The need for the nurse to assess personal values and responses is discussed. Barriers that may exist in the nurse/patient/family situation and hinder guilt resolution are also listed along with specific interventions to resolve guilt--the crisis within a crisis. Two case studies are included to demonstrate nurse and family interaction in a guilt crisis.     

Testing a predictive model of what makes a critical thinker

The goal of nursing education is to help individuals become self-determining, independent thinkers. Cognitive development may be the outcome that best characterizes such a thinker. The purpose of this study was to test a model of cognitive development in which four independent variables--knowledge base, critical thinking skills, critical thinking dispositions, and experience--were used to predict cognitive development. Data were analyzed from 232 practicing registered nurses. Three hierarchical levels of cognitive development were examined: dualism, relativism, and commitment. Critical thinking skill was a significant contributor only to the dualistic level of cognitive development. Critical thinking dispositions contributed to all three levels of cognitive development. Experience contributed only to the commitment level. The results of this study suggest that the development of a critical thinker may require time and experience. These findings can be used to examine current policy regarding the criteria used to evaluate nursing education.     

Forced use as a potential cause of gastrocnemius tears during neurologic rehabilitation: a report of 2 cases

Broadly defined, forced-use therapy uses specific techniques designed to engage the patient with brain injury in activities that disallow overcompensation with the noninvolved or less involved body segments while forcing the use of the more involved segments. Some applications may involve placing the patient's hemiparetic extremity in a closed-chain weight-bearing activity with therapist support. We describe 2 cases of gastrocnemius muscle tears that occurred during inpatient neurologic rehabilitation that may be attributed to forced use of the hemiplegic lower extremity. Each presented with signs and symptoms indicative of deep vein thrombosis of the calf but was later confirmed with magnetic resonance imaging to be muscle tears. Some closed-chain, forced-use activities may be ill advised in the early stages of rehabilitation or if force generation of the muscle is inadequate to provide a protective response to overstretching. Gastroc-soleus tears should also be considered in the differential diagnosis of unilateral or even bilateral lower-extremity swelling and pain in neurologically impaired patients who are undergoing forced-use therapy.     

Is chronic migraine one end of a spectrum of migraine or a separate entity?

Chronic migraine is associated with abnormalities in the periaqueductal grey that may be progressive. The condition is also associated with a greater degree of impairment in cortical processing of sensory stimuli than episodic migraine, perhaps due to more pervasive or persistent cortical hyperexcitability. These findings fit with the model of migraine as a spectrum disorder, in which the clinical and pathophysiological features may progress over time. This progression may result from changes in nociceptive thresholds and ensuing central sensitization caused by recurrent migraine in susceptible individuals. This may lead to changes in baseline neurological function between headaches, evident not only in electrophysiological and functional imaging studies, but also as psychological and somatic complaints that occur after years of episodic migraine. From current research and migraine models, a conceptualization of chronic migraine is emerging in which relatively permanent and pervasive central changes have occurred that warrant novel and tolerable treatments.     

Reflective thinking: turning a critical incident into a topic for research

Clinical nurses encounter critical incidents every day. While these may be a source of frustration they also have the potential to be turned into research projects so that problems can be examined and others can learn from them. This paper describes the reflective process used to generate a research project from a critical incident encountered in the clinical area.     

Paraneoplastic hypoglycemia associated with a hepatic hemangiopericytoma.

Hepatic hemangiopericytomas are rare vascular tumors that may be associated with profound hypoglycemia. Although this tumor is more likely to arise in the lower extremities, pelvis, or retroperitoneum, it may very rarely arise in the liver. Unlike other vascular liver tumors, hemangiopericytomas are frequently large at the time of appearance and may have characteristic imaging features. We present the correlative imaging findings in a patient who had a large symptomatic hepatic hemangiopericytoma that produced intractable and ultimately terminal hypoglycemia. Although hemangiopericytomas seldom occur in the liver, the associated hypoglycemia that is known to occur may suggest the diagnosis and may help in differentiating the mass from other large vascular tumors of the liver.     

microRNAs: a new class of breast cancer biomarkers

MicroRNAs (miRNAs) are regulatory molecules known to be aberrantly expressed in cancer and contribute to numerous aspects of tumor biology including the initiation, growth and spread of the tumor. With such diverse roles, it is becoming apparent that some may also provide valuable information which may be of use in a clinical setting, demonstrating the potential to act as both screening tools for the stratification of high-risk patients, while informing the treatment decision-making process. There is mounting evidence to suggest that some miRNAs may even provide assistance in the diagnosis of patients with breast cancer. In addition, miRNAs may themselves be considered therapeutic targets, with inhibition or reintroduction of a particular miRNA capable of inducing a response in vivo. This review focuses on miRNAs that have prognostic, diagnostic or predictive potential in breast cancer as well as the possible challenges in the translation of such observations to the clinic.     

Does EMTALA apply during a disaster?

A statement from Medicare says that disaster plans for transferring triaged patients may supercede the usual EMTALA requirements, but this is true only in certain scenarios. During a disaster, it's unacceptable to transfer a patient to a more appropriate facility if doing so amounts to refusal of lifesaving care. Don't assume that patients will be diverted successfully to appropriate facilities after a large-scale disaster. The required level of documentation under EMTALA may not be possible during a disaster, but some type of documentation is necessary.     

Building a data base for monitoring and facilitating health care

Our experience suggests that (1) comprehensive objective information is a valuable medical resource; (2) the systematic acquisition of objective information in a form suitable for computers is a necessary first step to building a useful data base; (3) when appropriately utilized, objective medical information may permit a study of medical practice, cost of care, and operational efficiency; (4) analysis of costs divorced from outcome and rehospitalization experiences may be misleading; (5) for some desired studies, the information required may be obtainable within a single institution. For others, however, community-wide studies may be the only possible way to obtain the information needed; (6) useful computer systems will be developed only if the health professionals become more knowledgeable (and demanding) and administrators are persuaded to provide effective support; and (7) effective hospital support for adequate medical information systems will probably come when criteria evaluating hospital performance are altered to reflect society's needs. Our experience with computer evaluation of care has been a sobering one. Still, it is obvious that the technology offers considerable hope that many inefficiencies in practice can be corrected. Considering all the current jeremiads about what we can afford in health care, it is reassuring to learn that good medicine is cost effective.     

When a hospice is not a haven

Abstract

There has been little research conducted with terminally ill patients in the UK to date. This case study describes statements made by a palliative care patient during a face-to-face interview while he was being treated in a hospice. His comments illustrate his unhappiness within the hospice environment to an extent that could compromise his holistic management in this setting. We would suggest that the important aspects of patient care include not just the major palliation issues of symptom control and good communications, but also attention to the rituals of daily living of individuals pertaining to the environment. The atmosphere of the hospice, as experienced by patients through their interactions with staff members within the care setting, is seen to be a significant factor for good holistic care. Hospices may need to be more aware of the impact that every member of staff, both clinical and non-clinical, can make at each patient contact. Becoming more alert to the likes and dislikes of each patient as regards the substance of these contacts may allow hospices to avoid institutionalized care practices and instead to individualize the care they offer to a greater number of their patients.