(2001). Eating Disorders: 2. Bulimia Nervosa. Hospital Practice: Vol. 36, No. 3, pp. 71-72.
Advances in understanding the biomolecular basis of the disease's inflammatory and remodeling responses are offering new therapeutic choices--and sometimes new drug-delivery systems--in categories such as beta-agonists, glucocorticoids, and leukotriene blockers. Meanwhile, researchers are exploring novel targets, including intercellular signals and cell-adhesion and gene-activating molecules.
of Medicine, Stanford, Calif. A 30-year-old woman was seen in the emergency department for chest pain and several near-syncopal episodes over the past two days. Her symptoms had begun suddenly, with diffuse nonpleuritic discomfort in the anterior chest, shortness of breath, and sweating. The chest discomfort was intermittent and not progressive, but she had had several episodes of nearsyncope while walking. The patient had been diagnosed more than 10 years earlier as having hemoglobin SC disease. She had chronic low-grade anemia and occasional crisis episodes that mainly involved pain in the lower extremities. Her medications included gabapentin, hydroxyurea, and folic acid. She appeared to be fatigued and was dyspneic on slight exertion. The temperature was 37.4, pulse 74 and regular, respirations 18, blood pressure 115/77, and arterial oxygen saturation 96o/o while breathing room air. There were no abnormal physical findings. The chest radiograph showed mild elevation of both diaphragms and a mild, ill-defined increase in density in the left lower lobe. The white blood cell count was 7,000 with a normal differential. The hemoglobin was 10.0, the hematocrit 30.2, and the platelet count 390,000. The ECG is shown. An ECG recorded 18 months earlier had been normal.
There are numerous causes of erectile dysfunction (ED), including psychogenic, organic, and mixed psychogenic/organic. Among the organic causes the most common include vascular, neurogenic, endocrine, structural, drug-induced, and others. Some have estimated that nearly one half of all causes of ED in men over 50 years of age are vascular in nature. This article reviews cardiovascular risk factors of ED.
As the survival of renal transplant patients has increased, so has their risk of significant morbidity. Immunosuppressive drugs can exacerbate preexisting conditions and promote development of new disease. Effective long-term care of transplant recipients requires an understanding of how these drugs affect clinical evaluations and treatments.
Management of pyoderma gangrenosum continues to be a therapeutic challenge, both because the low incidence of the disease makes it difficult to conduct large-scale randomized studies and because pathogenic mechanisms are not yet well defined. The selection of drugs and dosing schedules is therefore mainly guided by clinical experience.
Although a number of recent studies have challenged accepted beliefs about cardiovascular benefits, physicians should withhold judgment until ongoing randomized clinical trials are concluded. Patients without preexisting coronary artery disease may still be candidates for postmenopausal estrogen-progestin replacement—even if they have had breast cancer or have a family history of the disease.
Although many of the factors that contribute to anorexia nervosa are not within the physician's control, early detection and prompt initiation of treatment may improve patient outcome. A high level of suspicion and a willingness to address the issue can serve our patients well.
The medical choices are now more numerous: Dopamine agonists may have value not only for addressing the motor fluctuations of levodopa therapy but also for deferring the use of levodopa. Surgical choices are bolstered by the addition of investigational options such as neuronal transplantation, in addition to options currently approved, such as pallidotomy.
Dr. Hancock is Professor of (Cardiovascular) Medicine Emeritus. Stanford University School of Medicine, Stanford. Calif. A 91-year-old man with leg weakness and pseudoclaudication of four months' duration underwent lumbar laminectomy for intervertebral disc disease and spinal stenosis. He did not have heart disease or cardiac symptoms-the preoperative cardiovascular examination and ECG were normal. The operation was uneventful, and the patient's initial recovery was satisfactory. However, his stay in the intensive care unit was prolonged because of cough, fever, and pulmonary infiltrates. Borderline respiratory failure and intermittent hypoxemia developed On the sixth postoperative day, an arrhythmia was noted on the monitor. The 12-lead ECG recorded at this time is shown. What explains the differing QRS complexes? What explains the intermittent pauses in rhythm? Is a cardiologic intervention indicated?
A 38-year-old man presented with painful growths around his toenails. Since their first occurrence at age three, several had been surgically removed. He had had similar growths around his fingernails and multiple facial lesions since age seven.
The list of medications for both immune modulation and symptomatic relief continues to grow. Ideally, however, drug therapy should be part of a multidisciplinary approach that also includes such elements as patient education and physical therapy.
Streptococcus pneumoniae remains the leading cause of bacterial meningitis. While a new vaccine against this organism is now available, its impact on disease is not yet known. Strategies to guide the evaluation of patients and the treatment of antibiotic-resistant strains can help to improve outcomes in this dangerous disease.
(2001). Delirium: A Barometer for Quality of Hospital Care. Hospital Practice: Vol. 36, No. 2, pp. 15-18.
Prostaglandins produced by the COX-2 isoform of cyclooxygenase may be important for renal function--and perhaps even more so in diseases that render the kidney highly prostaglandin-dependent. COX-2 inhibitors may thus have much the same renal risks that a standard NSAID does. Several clinical trials have already focused on the new drugs' renal effects.
The single most common cause of sudden death in otherwise healthy young people, the disease is inherited by at least one in 1,000 to one in 500 of the general population. Nine genes are implicated; continued research can be expected to uncover others, along with modifying factors that offer hope of inducing regression. New interventions are being tested for value in addressing symptoms and risk of death.
