Tick-borne tularemia. An outbreak of lymphadenopathy in children

Between June 1 and July 15, 1984, twenty persons with glandular tularemia were identified on the Lower Brule and Crow Creek Indian reservations in South Dakota. The median age of the patients was 6 years (range, 2 to 20 years). The clinical illness was mild, consisting of fever, headache, and lymphadenopathy. All lymphadenopathy was in the head and neck area. Dermacentor variabilis ticks were identified as the vector. Although the mild clinical illness suggested Francisella tularensis, type B, was the agent, both type A and type B strains of F tularensis were isolated from ticks collected from dogs in the area. Tularemia is generally thought to be a severe systemic illness in North America. This outbreak illustrates that it can be a mild disease and that both type A and type B strains can be tick-borne and coexist in the same ecosystem.     

Kawasaki syndrome in Wisconsin

We reviewed cases of Kawasaki syndrome reported to the Wisconsin Division of Health and occurring in Wisconsin residents with illness onsets between 1982 and 1989. Of 164 reports, there were 73 confirmed cases that met the Centers for Disease Control case definition criteria for Kawasaki syndrome, 87 probable cases, and four non-cases. Confirmed cases were reported in residents of all five Wisconsin public health regions. The Wisconsin data was demographically similar to national data: 80% of the cases occurred in children younger than 5 years old, the mean annual incidence rate was highest in children 12 to 23 months of age, males were affected more often than females, and the incidence rate was higher among non-white children than among white children. Coronary artery aneurysms occurred in 16% of the patients with confirmed cases. Males developed aneurysms significantly more often than females, and aneurysm formation did not correlate with age. Kawasaki syndrome continues to occur in Wisconsin, and complete and accurate reporting of the disease will enhance the understanding of its natural history and etiology.     

Lyme disease during pregnancy

Lyme disease is an increasingly recognized tick-borne illness caused by a spirochete, Borrelia burgdorferi. Because the etiologic agent of Lyme disease is a spirochete, there has been concern about the effect of maternal Lyme disease on pregnancy outcome. We reviewed cases of Lyme disease in pregnant women who were identified before knowledge of the pregnancy outcomes. Nineteen cases were identified with onset between 1976 and 1984. Eight of the women were affected during the first trimester, seven during the second trimester, and two during the third trimester; in two, the trimester of onset was unknown. Thirteen received appropriate antibiotic therapy for Lyme disease. Of the 19 pregnancies, five had adverse outcomes, including syndactyly, cortical blindness, intrauterine fetal death, prematurity, and rash in the newborn. Adverse outcomes occurred in cases with infection during each of the trimesters. Although B burgdorferi could not be implicated directly in any of the adverse outcomes, the frequency of such outcomes warrants further surveillance and studies of pregnant women with Lyme disease.     

治疗森林脑炎用人免疫血清制备

目的：监测森林脑炎病毒感染人体后不同时间血清抗森林脑炎抗体水平和抗森林脑炎抗体血清体外保存（-50℃）时间,进行治疗森林脑炎用人免疫血清的制备。方法：应用间接免疫荧光抗体技术检测血清抗森林脑炎病毒抗体（IgG）滴度,确定人体感染森脑病毒后产生高滴度抗体时间和血清抗体体外保存时间。结果：人体感染森脑病毒2～3个月时血清抗森林脑炎病毒抗体（IgG）滴度最高、感染6个月抗体水平开始下降;血清体外保存6个月抗体水平保持不变,9个月后开始下降,24个月均无抗体。血清抗体滴度越高体外保存时间越长。结论：可以采集森林脑炎病毒感染后2～3个月已知高滴度抗体人群的血液,制备成治疗用免疫血清,分装冰冻（-50℃）保存。在次年森脑高发期及时用于临床病人的治疗,这将提高治疗效果,对减少该病的死亡率和致残率具有重要意义。     

HIV-1 among childbearing women and newborns in Wisconsin

To estimate the prevalence of antibody to human immunodeficiency virus-type 1 (HIV-1) among Wisconsin childbearing women (CBW), a continuous blinded HIV-1 seroprevalence survey is being conducted. This survey uses dried blood specimens obtained from infants as part of the Wisconsin Newborn Screening Program. From February 1989 through March 1990, 79,546 specimens from Wisconsin residents were tested for HIV-1 antibody, 21 (0.026%) were HIV-1 seropositive. Among specimens obtained from Milwaukee County CBW, 15 (0.076%) of 19,781 were HIV-1 seropositive compared to 6 (0.010%) of 59,765 obtained from other Wisconsin counties. After adjusting for maternal residence, Wisconsin minority CBW were six times more likely to be HIV-1 seropositive when compared to white CBW. The survey results underscore the need for strategies to prevent HIV-1 infection that focus on women of childbearing age in Wisconsin.     

High-altitude illness induced by tooth root infection

High-altitude illness may occur after recent pulmonary infection, but high-altitude illness after root canal therapy has not been described previously. A 44-year-old man is presented who skied to a 3333 m high peak in the Eastern Alps one day after he had undergone root canal therapy because of a tooth root infection. After 4 hours above 3000 m severe symptoms of high-altitude illness, including pulmonary oedema, developed. His condition improved after immediate descent. The next day he presented with local and general signs of infection which were successfully treated with gingival incisions and antibiotics. In conclusion, acute tooth root infection and root canal therapy may induce high-altitude illness at an altitude just above 3000 m.     

Eosinophilia-myalgia syndrome in Wisconsin

Eosinophilia-myalgia syndrome (EMS) is a newly recognized illness characterized by intense eosinophilia, debilitating myalgia, and absence of any condition that could account for the eosinophilia or myalgia. The disorder has previously been associated with ingestion of capsules containing the amino acid L-tryptophan. In 1989, the Wisconsin Division of Health began surveillance for EMS. Each of 25 persons reported with the illness and meeting a standardized case definition were using L-tryptophan when their symptoms began, between June 1989 and January 1990. The median age of the patients was 43 years (range 26-82 years); 92% were female, and 96% were white. The majority of patients reported were using L-tryptophan for insomnia (36%), premenstrual syndrome (28%), or depression (20%). Common signs and symptoms in these cases included cough or dyspnea (60%), arthralgia (44%), edema of the extremities (44%), fever (36%), and rash (32%). Other epidemiologic investigations to date suggest that EMS may be associated with a product contaminant.     

Seasonal arsenic exposure from burning chromium-copper-arsenate-treated wood

All eight members of a rural Wisconsin family experienced recurring neurological and medical illness over three years, especially during the winter months. Arsenic, in concentrations of 12 to 87 ppm, was noted in the hair of the mother and father, and analysis of hair and fingernails of all family members demonstrated pathological levels of arsenic. For four years the five-room home had been heated with a small wood stove in which outdoor or marine plywood and wood remnants had been preferentially burned. Stove ashes that contained more than 1,000 ppm of arsenic contaminated the living area, and the ratio of copper, chromium, and arsenic pentoxide in this ash matched the ratio used in the chromium-copper-arsenate-treated wood.     

Severe illness associated with group A-hemolytic streptococcal infections

The Wisconsin Division of Health (DOH) began surveillance for severe illnesses associated with group A beta-hemolytic streptococcus (GABS) infections in late 1989 to describe the current epidemiologic features and clinical spectrum of these infections in the state. Severe illness was defined by the isolation of GABS from the blood or by the development of one or more of the following in a patient infected with GABS: shock, extensive tissue injury, desquamating rash, disseminated intravascular coagulation, renal failure, adult respiratory distress syndrome, or death. Case reports involving 28 patients with severe GABS-related illnesses with onset from November 1989 through October 1990 were received by the DOH. The majority of the case-patients had sepsis (57%), cellulitis (50%) or both. Nine (32%) cases were fatal. Those who died were older than those who survived (median age 74 years v 43 years, p = 0.002) and were more likely to have clinical diagnoses that included pneumonia (relative risk [RR] 3.0, 95% confidence interval [CI] 1.2, 7.3) or necrotizing fasciitis/myositis (RR 3.7, 95% CI 1.5, 9.0). The median interval from illness onset to hospitalization was similar for fatal cases (1 day) and non-fatal cases (2 days), suggesting that early intervention after the appearance of clinical illness may not improve the outcome.     

《三指禅》中的脉学特点

周学霆熟知脉学渊源,所撰《三指禅》以对举法拈出缓脉,以定平人脉象,并用26种病脉互相对照,简捷易记,他提倡意会,昌明指下。对常见疾病采用脉,症,治紧密结合的方法,此书在脉学研究中占有一席之地。     

A defence of medical paternalism: maximising patients'' autonomy.

All illness represents a state of diminished autonomy and therefore the doctor-patient relationship necessarily and justifiably involves a degree of medical paternalism argues the author, an American medical student. In a broad-ranging paper he discusses the concepts of autonomy and paternalism in the context of the doctor-patient relationship. Given the necessary diminution of autonomy which illness inflicts, a limited form of medical paternalism, aimed at restoring or maximising the patient's autonomy is entirely acceptable, and indeed fundamental to the relationship he argues. However, the exercise of this paternalism should be flexible and related to the current 'level of autonomy' of the patient himself. An editorial in this issue comments briefly on this paper.     

Dengue haemorrhagic fever with unusual prolonged thrombocytopaenia

We describe a case of dengue haemorrhagic fever with prolonged thrombocytopaenia. A 22-year-old Malay man with no prior illness presented with a history of fever and generalised macular rash of four days duration. Initial work-up suggested the diagnosis of dengue haemorrhagic fever based on thrombocytopaenia and positive dengue serology. Patient recovered from acute illness by day ten, and was discharged from the hospital with improving platelet count. He was then noted to have declining platelet count on follow-up and required another hospital admission on day 19 of his illness because of declining platelet count. The patient remained hospitalised till day 44 of his illness and managed with repeated platelet transfusion and supportive care till he recovered spontaneously.     

Should children's autonomy be respected by telling them of their imminent death?

Respect for an individual's autonomy determines that doctors should inform patients if their illness is terminal. This becomes complicated when the terminal diagnosis is recent and death is imminent. The authors examine the admission to paediatric intensive care of an adolescent with terminal respiratory failure. While fully ventilated, the patient was kept sedated and comfortable but when breathing spontaneously he was capable of non-verbal communication and understanding. Once resedated and reintubated, intense debate ensued over whether to wake the patient to tell him he was going to die. The authors discuss the ethical arguments that surrounded their decision.     

Babesiosis in Wisconsin. A new focus of disease transmission

A confirmed case of human babesiosis was identified in August 1983 in a 54-year-old asplenic Wisconsin resident. Babesia microti was identified as the causative agent by blood smear morphology and hamster inoculation techniques. The patient's wife had clinically confirmed Lyme disease in 1981 and had serologic evidence (immunofluorescent antibody to a B microti titer of 1:1,024) of recent Babesia infection in August 1983. Mice (Peromyscus species) trapped on the patients' property and elsewhere in their Wisconsin county of residence were infected with B microti. Lyme disease and babesiosis have the same tick vector and animal reservoir; serum samples from 116 Wisconsin and Minnesota residents with clinically confirmed Lyme disease between 1980 and 1983 were tested, and none were found to have concurrent Babesia infection. This area of Wisconsin is identified as a new focus for babesiosis transmission, but the risk of transmission seems to be low.     

Development and operation of the Wisconsin Research Network

In 1987, the Wisconsin Academy of Family Physicians developed the Wisconsin Research Network (WReN) to support practice-based primary care research throughout Wisconsin. WReN has three objectives: to support the research efforts of individual physicians in community practices, to facilitate collaborative research among practicing physicians, and to provide academically based investigators with access to community practice sites. Due to a policy of actively encouraging membership, WReN has grown to 460 members during its 4-year history. Five WReN-supported papers have been published, and 22 state and national level presentations of WReN-supported research results have been made. Competitive grants totaling more than $2 million have been awarded to university-based investigators for studies using the resources of WReN. This paper describes the development, organization, and success of WReN as well as the challenges which must be addressed.     

AIDS and HIV in Wisconsin: projections for the decade

Based on a projection model developed by the Wisconsin AIDS/HIV Program, at the beginning of 1990 there were between 7,143 and 11,957 HIV-infected persons in Wisconsin. During the 1990s the cumulative number of HIV-infected persons in the state may more than double to between 16,471 and 25,932. We project that between 6,329 and 9,489 new cases of acquired immunodeficiency syndrome (AIDS), and between 3,577 and 5,365 AIDS deaths will occur in Wisconsin in next ten years. This is a greater than 13-fold increase in AIDS cases over the 1980s. By the end of the 1990s, the number of persons living with AIDS is projected to be ten-fold greater than the currently estimated number. To make plans for the future, policy makers need to be aware of this expected large increase in HIV-related morbidity and mortality.     

Darwin's illness revealed

After returning from the Beagle in 1836, Charles Darwin suffered for over 40 years from long bouts of vomiting, gut pain, headaches, severe tiredness, skin problems, and depression. Twenty doctors failed to treat him. Many books and papers have explained Darwin's mystery illness as organic or psychosomatic, including arsenic poisoning, Chagas' disease, multiple allergy, hypochondria, or bereavement syndrome. None stand up to full scrutiny. His medical history shows he had an organic problem, exacerbated by depression. Here we show that all Darwin's symptoms match systemic lactose intolerance. Vomiting and gut problems showed up two to three hours after a meal, the time it takes for lactose to reach the large intestine. His family history shows a major inherited component, as with genetically predisposed hypolactasia. Darwin only got better when, by chance, he stopped taking milk and cream. Darwin's illness highlights something else he missed--the importance of lactose in mammalian and human evolution.     

Comprehensive History Taking for the Non-Psychiatrist

To an increasing degree the psychiatrist is oriented to the community and general hospital either as consultant, therapist, or collaborator in overall patient management. In these new roles, he becomes a more comprehensive physician and also conveys psychiatric insights to his colleagues.

Psychological factors and the patient's personality “style” influence the development and course of every disease, complicating diagnosis and effective treatment. It is a basic requirement that a good working alliance be established between patient and physician. This is assisted by comprehensive history taking, which clarifies the lifesetting in which the illness began, the patient's personality and his habitual reactions of emotional regression under stress. It will also point up errors introduced by the patient, omissions, and distortions in offering the subjective data which the physician must evaluate.

Seven major personality types and appropriate physician responses are outlined: the dependent demanding oral patient, the orderly controlled obsessive, the dramatic seductive hysteric, the long-suffering masochist, the querulous paranoid, the overbearing narcissist and the aloof withdrawn schizoid.

The non-psychiatrist can resolve complex and puzzling medical problems if he has an increased awareness of how emotional forces complicate illness and if he can exploit comprehensive history taking to the full.

     

Malaria in Wisconsin 1981-1989: a review of cases and update on chemoprophylaxis

Malaria continues to be a significant cause of travel related morbidity and mortality for US citizens. Yet there have been no previous analyses of malaria cases reported in Wisconsin. To provide timely information to Wisconsin physicians, the authors present a review of reported malaria cases in Wisconsin for the years 1981 through 1989, and an update of current Center for Disease Control malaria chemoprophylaxis.     

Histiocytic cytophagic panniculitis

A 33 year old man developed fever, malaise, jaundice, pancytopenia, coagulation abnormalities, hepatomegaly, pleural effusions and a subcutaneous lump. Biopsies revealed a lobular panniculitis with the presence of cytophagic histiocytes; erythrophagocytosis was also demonstrated in the liver and bone marrow. Despite the use of chemotherapy (CHOP) his clinical condition deteriorated and he died 5 months after presentation. This illness is consistent with the recently described syndrome of histiocytic cytophagic panniculitis.