Swallowing (or deglutition) syncope is an uncommon, vagally-mediated etiology for syncope that may be seen in children and adults. The mechanism of syncope involves afferent impulses from the upper gastrointestinal tract and efferent impulses to the heart that can produce a variety of bradyarrhythmias with atrioventricular block. Two cases of swallow syncope are reported, one associated with drinking a cold carbonated beverage, and the other precipitated by eating a large bolus of food (which we have termed "Vaso-Bagel" syncope). In evaluating patients with syncope, a history of a temporal relationship to eating or drinking should be sought. While changes in eating habits may be effective in some cases, permanent pacemaker placement is often indicated and is curative.
Cat scratch disease is usually a self-limited illness associated with tender lymph nodes, fever, malaise, and fatigue. Lymphadenopathy usually resolves spontaneously within three to four months. Cat scratch disease can be atypical as indicated by the presentation of our patient.
The clinical course of a case of bird fanciers' lung is described along with the considerations that are important in the management of this form of hypersensitivity pneumonitis. Diagnostic parameters, therapeutic considerations, and environmental issues are discussed in the context of the current literature.
This article provides the history of health care provisions for seamen in Baltimore and presents an analysis of the distribution of diseases of merchant seamen in baltimore in 1995.
The use of shoulder manipulation in the treatment of frozen shoulder syndrome remains controversial. Opponents cite the risk of dislocation, fracture, nerve palsy, and rotator cuff tearing as limiting the usefulness of manipulation. A retrospective study of 38 shoulder manipulations in 32 patients was performed. These patients were followed for an average time of 58 months. The patients were examined in follow up for combined shoulder range of motion, external and internal rotation strength, and status of the long head of the biceps. Manipulation was performed in all patients by the senior author and supervised physical therapy was begun within 24 hours of the manipulation. The average recovery time was 13 weeks. In this series, 97% of patients had relief of pain and recovery of near complete range of motion, although 8% required a second manipulation to obtain a successful result. Mild weakness to manual muscle testing was present in 5.3% of patients in external rotation and 10.5% of patients in internal rotation. There was no deterioration of shoulder function with time. In fact, most patients improved with passage of time, even more. There was no evidence of biceps tendon rupture or rotator cuff insufficiency at the time of follow up in any of the patients. No fractures, dislocations or nerve palsies were observed, although one patient who had no premanipulation arthrogram was found to have a rotator cuff tear a few months after failed manipulation. Manipulation of the shoulder can therefore be offered to reduce the pain and period of disability in patients who fail conservative treatment of frozen shoulder syndrome.
Medical students from University of Maryland and Johns Hopkins University, with a grant from the Maryland Chapter of the American College of Physicians, held a free health fair in a Baltimore City neighborhood. The goals were to heighten awareness of common health problems, learn more about a medically underserved community, and increase access to primary care services in that community. The students planned booths to offer information and screening on 19 common health topics. Fair organizers worked with a local clinic, People's Community Health Center, and a neighborhood development organization, the Safe and Smart Center, to create an event that would engage and educate people on relevant issues. Approximately 100 medical students participated in the event and 350 people attended the fair. An optional survey filled out by fair participants revealed that a diverse group of people attended the event. Comments about the day from medical students and fair participants show that the event was enjoyable and offered a tremendous learning opportunity for both groups. This paper also discusses problems that arose during the planning stages as well as suggestions for those interested in planning a similar event.
Axillary lymph node dissection is the gold standard for staging breast cancer, but it is associated with significant morbidity and complications. Sentinel lymph node mapping technique has demonstrated a successful detection of the node or nodes more likely to have metastasis. Two techniques are being used to detect sentinel lymph node-intraoperative use of gamma detecting probe after injection of radio tracer preoperatively and the injection of blue dye and lymphatic mapping intraoperatively. We used both techniques. Twenty-four patients underwent sentinel lymph node mapping. Blue dye and gamma detecting probe identified sentinel lymph nodes in 78% and 77% of patients, respectively. Overall, 23 of 24 patients had a sentinel lymph node identified (96%). Ten patients had metastatic disease in the axilla. Out of these ten patients the only positive node/nodes were the sentinel lymph node in six patients. The other four patients had positive non-sentinel lymph node along with positive sentinel lymph node. All of the patients who had metastatic disease in the axilla were detected by the sentinel lymph node mapping technique. Therefore, no patient had positive non-sentinel lymph node if the sentinel lymph node was negative. This technique was 100% predictive of the axillary status. Sentinel lymph node mapping technique will change the management of breast cancer and will allow two-thirds of the patients with breast cancer to be managed without axillary lymph node dissection with a resulting reduction in morbidity and cost.
Reactive arthritis is a term used to describe a sterile inflammatory arthritis occurring after a documented infection elsewhere in the body. Group A streptococcus is known to cause such an arthropathy in the setting of acute rheumatic fever. Friedberg first postulated that a reactive arthritis might occur in response to a streptococcal pharyngeal infection as a separate entity from rheumatic fever in the 1950s. Then, in the 1980s, other investigators began describing cases of reactive arthritis that were not characteristic of acute rheumatic fever based on certain observations and application of criteria. We present a patient whose clinical features are more consistent with post-streptococcal reactive arthritis than acute rheumatic fever.
The need for all medical institutions that treat carotid artery occlusive disease to continuously monitor their surgical experience is quite evident. Nonetheless, a national survey in 1995 found that only 15% of physicians reported knowing the perioperative stroke rate at the hospitals where they perform or refer patients for carotid endarterectomy. Neurologic morbidity related to the performance of carotid endarterectomy has been continuously monitored at Howard County General Hospital for the past decade, but the true significance of this data could not be appreciated without a more comprehensive analysis of the clinical experience. The present study was undertaken with the intent of providing this information.
Based on recent epidemiologic evidence, AIDS in older persons (ages 55-79) in Maryland appears to be increasingly contracted heterosexually, particularly in women. Little is known about sexual practices or beliefs about HIV in older persons living in high HIV prevalence urban populations. The purpose of this study was to assess sexual practices, particularly high risk behavior, modifications of behavior including condom use, and perceptions of risk. A behavioral survey, containing 41 potential responses, was developed through modification of The National AIDS Behavioral Survey, focusing on heterosexual activity. The survey was administered to a convenience sample of 55 to 79 year olds attending the Union Memorial Hospital medical clinic. Sexual activity is common within the older population, especially among men. Multiple partners is not unusual in older men. Condoms are commonly used. Older individuals typically are aware of HIV heterosexual transmission risk and a proportion have modified sexual behavior because of perceived risks.
The genus Hantavirus, family Bunyaviridae, comprise at least 20 distinct viruses. Ten of these have been linked to specific human diseases. Hemorrhagic fever with renal syndrome has been recognized since the 1950s. Hantavirus pulmonary syndrome was recognized in the United States in 1993. Epizootiologic studies of Norway rats in the Baltimore area have shown that rodent infections with hantaviruses are common and geographically widespread with prevalence reaching 44% in tested rat populations. These viruses are antigenically related to the Seoul virus. Hantavirus infections in humans occur through transmission from a rodent reservoir, primarily by inhalation of virus laden rodent excreta. There is no evidence to support person-to-person transmission of any known Hantavirus. To establish the prevalence of Hantavirus infections in humans in the Baltimore area we collected sera from 1,212 persons attending a community based health care system. These were tested for antibodies against three reference Hantavirus strains: Hantaan (HTN), Seoul (SEO), and Convict Creek (HN017). HN017 was chosen to represent the SinNombre (SN-like) strains of Hantavirus. Sera from nine patients were positive to Hantavirus specific antibodies, HTN, and SEO by Enzyme Linked Imuno Sorbent Assay (ELISA). No sera were positive for HN017 antigen. All sera that were positive for HTN and SEO were tested by western blot for HTN. All nine sera were confirmed positive by western blot. This suggests that unrecognized infections with Hantaan or Seoul-like viruses occur in the Baltimore area in humans, although the prevalence rate in humans is low (0.74%). Epidemiologic monitoring may be warranted to establish the health implications of these infections.
Speculation about the future of medicine is risky. Few would have predicted five years ago the sweeping changes that have occurred. Nonetheless, an analysis and projection of current trends would suggest that further substantial changes await us. These include, among other things, a return of double-digit inflation in health care, an increase in governmental oversight, an opportunity for both patients and physicians to reestablish their influence, a strain upon traditional medical ethics, and no resolution to the issues involving the uninsured. Taken together, these projections suggest a real need for physicians to be involved in helping to assure that those positive developments come to pass and that those unfavorable do not.
The following case presentations illustrate the diverse clinical manifestations and benign self-limited course of spontaneous pneumomediastinum. The discussion includes the mechanisms involved, the symptoms, the radiographic findings, the potential complications, the exclusionary diagnosis, and the appropriate management of this condition.
The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) provided guidelines for the treatment of hypertension. This study examined the adherence to the JNC VI guidelines by a retrospective chart review of patients treated for hypertension in the internal medicine house staff practice at a university teaching hospital in the year after publication of the JNC VI.
Current practice standards indicate the need for tube thoracostomy in the management of clinically significant recurrent pleural effusions. The following case presentation and review of the literature illustrate a contraindication to chest tube insertion with pleural effusions associated with portal hypertension (hepatic hydrothorax) and suggest alternative therapies.
