Upper Gastrointestinal Hemorrhage—Diagnosis and Management

The current management of a patient with upper gastrointestinal hemorrhage involves three steps: initial correction of unstable hemodynamics, obtaining the specific diagnosis of the lesion responsible for gastrointestinal blood loss, and therapy directed at the specific bleeding lesion. The current approach to upper gastrointestinal hemorrhage is carrying out upper gastrointestinal endoscopy following stabilization of the patient. Although improved morbidity and mortality statistics have been slow to appear, the use of endoscopy permits appropriate therapy directed at the specific lesion. Specific therapeutic measures have been outlined for seven common causes of upper gastrointestinal hemorrhage. The advent of therapeutic endoscopy promises to bring further advances in therapy in the near future.     

RHEUMATOID ARTHRITIS—Current Therapy and Medical Management

Although no routinely effective therapy for patients with rheumatoid arthritis is available, certain established principles of management and a variety of medications do provide benefit.Conservative management programs may suffice in milder cases. Aspirin or other salicylates and physical therapy are the mainstays in such programs.The antimalarial drugs may be helpful in a small proportion of cases. Steroids have had beneficial effect rather consistently and, with the newer analogues, certain side effects have become less troublesome. The usual precautions with the use of these compounds must be observed as always. Chrysotherapy remains important in the treatment of severe cases, and its use should not be postponed until major destructive joint changes have occurred.     

REFRACTORY HYPOTENSION—Diagnosis and Management in Surgical Patients

Refractory hypotension is circulatory collapse of obscure cause which occurs in surgical patients who are thought to have a normal blood volume but in whom adequate circulation cannot be maintained. Such patients are usually treated empirically by the administration of intravenous vasopressor agents, and the mortality rate is relatively high.A specific diagnosis of the underlying cause for the refractory hypotension can be made by thorough clinical evaluation. Specific treatment aimed at correcting the underlying cause of the vascular collapse will lower the mortality rate in this serious type of circulatory failure.     

Botulism—Diagnosis,Management and Public Health Considerations

Botulism is an uncommon but often fatal disease associated with ingestion of a potent neurotoxin present in improperly preserved foods. Exposures to commercially preserved foods with an odd or peculiar taste almost never represent exposure to botulism toxin. Improperly prepared home-canned products which are tasted or consumed without heating are more likely to be associated with botulism.The management of suspect and confirmed cases of botulism is presented by medical epidemiologists in the State Department of Public Health, Bureau of Communicable Disease Control, to provide physicians in California with a practical approach to this problem.     

URINARY TRACT INFECTIONS—Problems in Medical Management

The lesion principally responsible for chronic, or recurrent, urinary tract infection is a focus in the interstitial tissue of the kidney. Most cursory antimicrobial therapy suppresses the manifestations of lower urinary tract involvement but does not eradicate the renal focus. In order to cure rather than merely suppress the infection, it is imperative that, as early as possible, steps be taken to isolate and identify the etiologic microorganism and to determine its sensitivity to antimicrobial agents. Based on this information sufficient amounts of drug should be given for an adequate period (probably at least two weeks) to eradicate the infection within the renal tissue. Such a program would tend to reduce the number of cases in which irreversible renal failure develops from chronic pyelonephritis.     

Acutely Suicidal Patients—Management in General Medical Practice

Suicidal crises are best understood as late stages in the progressive breakdown of adaptational behavior in emotionally exhausted patients. The premonitory symptoms of suicide include verbal communications, suicide attempts, symptomatic actions, depression, treatment failure, excessive emotional reactions to specific disease states and panic reactions.Of persons who committed suicide, 75 per cent had seen a physician within six months. To recognize and evaluate suicide danger the physician must not be afraid to question the patient directly about his suicidal plans. The average physician encounters half a dozen suicidal patients a year and will have 10 to 12 suicides in his practice during a long career.In treating suicidal patients, the physician should maintain his medical attitude. The patients need emergency medical care including appropriate drugs. Free communication between patient and physician is very important. This may take some extra time. Patients benefit from emergency psychological support and stimulation toward constructive action. Family, friends, and community agencies should be mobilized to aid the patient. For seriously suicidal patients, consultation is recommended and treatment in hospital is advisable.     

THE SIGNIFICANCE OF INFECTION IN ALLERGIC DISEASE—Its Influence on Diagnosis and Management

The presence of infection in allergic disease produces a confused picture in which two different causative factors must be clearly separated by the physician if he is to treat the patient successfully. The effects of infection are not consistent. There are situations, as seen in infectious diseases, where symptoms of allergic disease are temporarily relieved and others where the infection may intensify or precipitate the allergic condition. It is likewise important to recognize the complications superimposed upon allergic disease by infection. In such cases, control of the infection is as dependent upon control of the allergy as it is upon antibiotics.     

Traffic Accidents—Epidemiology and Medical Aspects of Prevention

Injuries and deaths from traffic accidents are a public health problem of epidemic proportions and justify intensive epidemiological research. The human factor is responsible for the majority of traffic accidents. The literature concerning the human factor is reviewed, and it is concluded that psychosocial influences are most important, though medical conditions may be responsible for 3 to 4% of accidents. Problems concerning the medical examination of drivers are discussed and the need is emphasized to find some means of removing from the road those drivers who continue to drive in spite of repeated medical advice not to do so. Some of the medical conditions influencing driver safety are discussed. It is recommended that each Division of The Canadian Medical Association should publish a guide for physicians who examine drivers. The advantages of a uniform guide in Canada are stressed.     

Depression in Medical School: The Influence of Morningness‐Eveningness

Medical students are at higher risk for depression, affecting not only their lives but also patient care. This article studied a population of medical students engaged in lecture‐based learning regarding the presence of depressive symptoms and its relation to morningness‐eveningness. Depressive symptoms were assessed by the Beck Depressive Inventory scale (BDI>10), and diurnal preference was assessed by the Horne & Östberg Morningness/Eveningness Questionnaire (MEQ). Family history of depression and involvement in regular physical activity were also investigated. A total of 161 students, 77 (47.8%) males, aged 19 to 30 yrs (22.1±2.1) living in a city close to the equator were evaluated. Fifty‐three individuals (32.9%) had depressive symptoms. Depressive individuals showed a trend to be female (p=0.07). Also, female gender showed a non‐significant shift toward morningness. Fifty‐eight (36.0%) subjects participated in regular physical activity. In 57 cases (35.4%), there was a history of depression in the family. Fifteen individuals (9.3%) were definitely evening type, 42 (26.1%) were moderately evening type, 44 (27.3%) were indifferent, 42 (26.1%) were moderately morning type, and 18 (11.2%) were definitely morning type. Family history of depression (OR=0.29, 95% CI=1.37–6.12) and sedentary life (OR=0.28, 95% CI=0.12–0.65) were associated with depressive symptoms. Eveningness was associated with depressive symptoms (OR=0.66, 95% CI=0.50–0.88), and this association remained significant after adjusting for the presence of familial depression and physical activity (OR=0.71, 95% CI=0.52–0.95). In conclusion, depressive symptoms are independently associated with “eveningness” in medical students. These results should be confirmed by future studies involving a larger number of subjects.     

WHIPLASH INJURIES—Diagnosis and Treatment

Whiplash injury may extend far beyond the neck, and may involve even the soft tissues of the pelvis. For permanent recovery, all the injuries must be evaluated and treated together.When impact from the rear snaps the head back and then forward, posterior subluxations in the cervical spine cause anterior-posterior narrowing of the intervertebral foramina, which may result in injury to the cervical nerve roots. Impact at the front, causing hyperflexion followed by hyperextension, has a similar effect although usually not as severe. Resulting symptoms may not appear until two or three weeks later, when irritative lesions have developed because of hemorrhage or swelling. Mild or progressive degenerative changes may cause no symptoms but may predispose the affected area to injury following some slight trauma. Capsular ligaments of the lateral intervertebral joints are especially liable to whiplash injury which may give rise to scars and adhesions that compress spinal nerves. Sympathetic system involvement may cause reflex and referred pain.Detailed neurologic, roentgen and electromyographic studies may be necessary for proper evaluation of injuries. Seemingly psychosomatic pain or disability is likely to have some physical basis in whiplash injuries.In 33 patients with whiplash injury, some recently injured and some chronically disabled with persistent symptoms, good results were observed following hydromassage, hot packs, joint mobilization exercises and, in a few, cervical or pelvic traction.     

HYPOPARATHYROIDISM—Medical and Surgical Aspects

Hypoparathyroidism is almost invariably a complication of operation on the thyroid gland, and the diagnosis usually presents no problem. Fairly good control of the symptoms is possible by medical management, but, since substitution therapy is not available, the treatment of hypoparathyroidism is not completely satisfactory. Parathyroid homografting has been attempted; at present, however, grafting procedures must be considered experimental.