Seeking psychological treatment as a cure for a medical problem.

Today health care providers are more likely to experience legal, moral and ethical dilemmas regarding their treatment principles given the climate of health care. Clinical practice in the United States is being affected by many external forces which can affect patient care. Government and insurance companies are attempting to legislate treatment as evidenced by DRG's and reimbursement patterns. Hospital and clinic administrators are pressuring faculty and staff to increase revenue by participating in more income generating activities. Within this milieu of dwindling resources, consumers continue to demand a variety of health care services. A case example of a woman who asked for a psychological intervention to treat a medical condition is presented. This case focuses on the important issue of offering efficacious treatments to informed patients with carefully diagnosed disorders. Whether scientific, ethically-based treatments are being rendered when any of the criteria, efficacious, informed and diagnosed are altered or missing, is open to doubt. This case is presented, not as a model of clinical management, but rather to stimulate discussion and generate ideas on how to better address future situations: (a) Where the patient requests an available treatment for a problem which would not be directly helped by such treatment; (b) how far must a clinician go to insure that informed consent has been reached?; (c) what is the physician's responsibility in providing what a patient wants in the way of treatment?; and (d) conversely, should clinicians provide medical interventions (at the patient's insistence) for psychological problems, for example, provide a penile prosthetic implant to a man whose disorder is clearly psychogenic impotence?     

Hodgkin disease: contributions of chest CT in the initial staging evaluation

Chest radiographs and chest computed tomography (CT) scans were compared in 203 patients with newly diagnosed Hodgkin disease. The incidence of positive findings was tabulated from six intrathoracic lymph node groups, lung parenchyma, pericardium, pleura, and chest wall. The discordant cases were assessed to determine impact on clinical management. The CT scans provided additional evidence of disease involvement, ranging from 0% to 15% at each of the designated anatomic sites. Treatment was altered in 9.4% of all patients (19 of 203), including 13.8% (nine of 65) of those undergoing radiation therapy alone and 8.2% (ten of 122) of those undergoing combined-modality treatment. We conclude that routine chest CT examinations are valuable in the clinical management of those patients for whom radiation therapy is planned.     

The use of deep inspiration preceding the valsalva maneuver and rapid expiration in color doppler imaging of the lower extremity veins

Deep inspiration preceding Valsalva maneuver and rapid expiration immediately following it (DIVE) enhance venous blood flow on color Doppler flow imaging (CDI). The effect of DIVE was assessed in 115 consecutive lower extremity examinations. Of these, 95 or 115 (83%) had negative CDI sonograms, and 20 of 115 (17%) had partially (six of 115) or completely (14 of 115) occluding deep vein thrombosis. DIVE enhanced venous blood flow in 68% of the negative cases, resulting in transient venous distention, and/or more complete color filling, and/or greater spectral flow velocities. The 14 cases with completely occluding thrombi showed no response to DIVE. Six cases with partially occluding thrombi showed moderate to mild response to DIVE, with improved color delineation of the residual patent lumen around the thrombus. The authors conclude that DIVE facilitates deep venous CDI, especially when compression cannot be used to augment venous flow.