The Western journal of medicine最新文献

{"title":"Skin nodules and back pain.","authors":"S. Goorha, T. Lahey","doi":"10.1136/EWJM.176.1.15","DOIUrl":"https://doi.org/10.1136/EWJM.176.1.15","url":null,"abstract":"QUESTION: A 50-year-old man who had recently completed consolidation chemotherapy for acute myelocytic leukemia presented with lower back pain radiating to his right leg. He did not have bowel or bladder incontinence. The patient also reported the growth of multiple greenish skin nodules a few weeks before presentation (figure 1). A bone marrow biopsy had been negative for leukemic cells 1 month before presentation. Figure 1 Skin nodule, 12 mm in diameter On physical examination, the patient had a normal gait and sensation but a decreased ankle reflex, and the straight leg raising test was positive on the right side. Several 1- to 2-cm nontender greenish nodules were present on his trunk and thighs. What is the origin of this patient's skin condition, and how does it relate to his lower back pain? ANSWER: This patient has chloromas (granulocytic sarcomas) of his skin and meninges, the latter causing spinal nerve root compression. A chloroma is defined as a green tumor consisting of leukemic cells, with the combining form of the word, “chloro-” being derived from Greek for green (as in chlorophyll). The green color is most noticeable surrounding the red papule on the skin in figure 1. Magnetic resonance imaging of the spine (figure 2) showed diffuse leukemic infiltration throughout his spine, causing compression of his cauda equina, and a subsequent lumbar puncture revealed lymphoblastic cells. A biopsy of the patient's skin nodules confirmed the presence of leukemic cells (figure 3). Figure 2 Spinal magnetic resonance image showing cauda equina compression (arrow) Figure 3 Skin biopsy showing an infiltrate of leukemic cells Chloromas are a rare manifestation of both acute myelogenous and acute lymphocytic leukemia. They usually are seen in younger patients with leukemia and have been described in almost every anatomic location. In most cases, the tumor is associated with coexisting acute leukemia; in fact, it may herald a hematologic relapse, as in this patient.1 Histologically, a chloroma is composed of sheets of primitive cells of the myeloid or monoblastoid type. The greenish tint of the tumor is due to myeloperoxidase found in the neutrophilic leukocytes. The conditions most likely to be confused with chloroma (if the diagnosis of leukemia has not already been made) are histiocytic lymphoma and eosinophilic granuloma.2 Chloromas rarely cause spinal cord compression.3 Most cases of acute cauda equina syndrome are caused by mechanical compression of spinal nerve roots by either tumor or infection. The most common neoplastic causes of spinal cord compression include prostate, breast, and lung cancer. The treatment of cauda equina syndrome requires urgent decompression of the involved nerve roots, with radiation therapy, the administration of steroids, chemotherapy, or surgery.4 The patient underwent urgent total spine irradiation, which resulted in rapid lessening of his lower bac","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"59 1","pages":"15-6"},"PeriodicalIF":0.0,"publicationDate":"2002-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77906095","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Fear and loathing on the care path: treating pain and suffering.","authors":"P. Fine","doi":"10.1136/EWJM.176.1.17","DOIUrl":"https://doi.org/10.1136/EWJM.176.1.17","url":null,"abstract":"Two recent court cases have gained widespread media attention and may create considerable worries among physicians. A precedent-setting verdict in a recent California case found, for the plaintiff, that insufficient pain management in a dying patient constituted abuse by a physician.1,2,3 In Utah, a physician who provided comfort care to terminally ill patients was accused of performing euthanasia, and he was tried on 5 counts of first-degree murder. He was convicted on several counts of negligent homicide and aggravated manslaughter.4 The conviction was over-turned after 6 months of imprisonment. This was due to the prosecutors' failure to disclose exculpatory evidence consisting of information revealed to the prosecution just before trial that care, as documented, reflected a good-faith effort to provide ethically justified treatments that may or may not have contributed to the timing of these patients' deaths. There is good cause for nervousness. These cases are a loud wake-up call to the medical profession. Fears of doing too little or too much should strongly motivate providers to attend carefully to the needs, goals, and values of their patients (or proxies). Clearly, the public is now demanding proficiency in palliative care, and it is a correct assertion that much can be done to mitigate suffering in the vast majority of cases without either killing patients or allowing intolerable distress. It is not surprising that most patients and their families know very little about palliative interventions and so act in seemingly irrational ways. Unfounded fears that opioid analgesics inevitably lead to addiction or hasten death are typical examples we must overcome through informed dialogue and counseling. However, we cannot enlighten them if we have not educated ourselves. Anxieties that physicians may have about being helplessly trapped by the public's current expectations into one type of error or another are certainly valid if they are insufficiently educated and trained in this area. With training and experience, it is rare that a physician would find herself or himself caught in one of the untenable extremes of what is actually an extensive and relatively safe field of palliative management strategies. However, like all other clinical areas that require expertise, what may be comfortable ground for knowledgeable and skilled practitioners may feel like a razor's edge to the ill prepared. What should scare us the most is not knowing and not acknowledging what we don't know. The obligation to know one's strengths, weaknesses, and limitations is fundamental to the integrity of our profession. Should the ethical imperatives to assess and relieve suffering be insufficient motivation, these legal cases should inspire each of us who cares for patients with chronic diseases, especially in their advanced states, to attend closely to quality-of-life issues. Individual physicians, medical societies and specialty organizations, schools of medici","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"21 1","pages":"17"},"PeriodicalIF":0.0,"publicationDate":"2002-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73954057","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Ending the cycle-turning crisis into opportunity in Afghanistan: humanitarian aid efforts can help create community self-reliance.","authors":"K. Starr","doi":"10.1136/EWJM.176.1.6","DOIUrl":"https://doi.org/10.1136/EWJM.176.1.6","url":null,"abstract":"Afghanistan teetered on the edge of the abyss even before the bombs began to drop. While watching war coverage on TV, one is barraged by a numbing litany of appalling health statistics: one of four children does not survive to the age of 5, only one in five Afghans has access to clean water, maternal mortality rates are the highest in the world, life expectancy is in the low 40s—it goes on and on.1,2 Last summer, the harvest failed again, and between the threats of starvation and bombing, countless Afghans left their homes to join a swarm of internal refugees looking for a haven that didn't exist. The crisis, though, has presented an opportunity. Although the situation remains volatile and unpredictable, a massive aid effort has been mobilized. Many Afghans are still at risk of hunger, exposure, and disease, but their numbers are far less than the 7.5 million estimated by the United Nations in late September.3 The magnitude of resources and proposed effort is unprecedented, and now the flickering prospect of peace creates the possibility that this aid can lead to lasting change. Where to begin is a hard question for health professionals. We are not prepared to deal with chaos and starvation, and our best efforts disappear into a gaping maw of endless need. If we step back and take a triage approach, Afghanistan's most critical health needs are food, stability, and the rebuilding of civil society. In recent years, war and drought have created a disastrous synergy: the drought multiplies the effects of 22 years of war, and ongoing political chaos disrupts the famine relief efforts. In the absence of the institutions and infrastructure that make up civil society, little can be done to create lasting change. Stability, the availability of food, and the rebuilding of civil society are intertwined goals. To create the stability needed to break the cycle of crisis, food must be delivered in a way that keeps people in their homes and that starts the long process of rebuilding. In the fall of 2000, I traveled far into the remote central plateau of Afghanistan to visit a project that was taking an integrated and proactive approach to crisis by using famine relief as a way to jump-start the rebuilding of civil society. UN wheat trucked over the high mountain passes from Kabul served as a catalyst for mobilization around community projects and the revival of decision-making councils. Assured that they could survive in their villages, people began to invest in their future again. With something productive to do, Kalashnikov-toting young men left their gangs and joined other men to rebuild their community infrastructure. Experience in China, India, and Peru shows that similar processes of building self-reliance through community mobilization can grow rapidly when they are part of a well-designed strategy that is supported by leaders and outside experts.4 This sort of integrated grassroots approach is what is needed to tackle Afghanistan's ongoin","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"68 1","pages":"6-7"},"PeriodicalIF":0.0,"publicationDate":"2002-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73088853","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"End-of-life decisions in a developmental center: a retrospective study.","authors":"G. Lohiya, L. Tan-Figueroa, Hugh Kohler","doi":"10.1136/EWJM.176.1.20","DOIUrl":"https://doi.org/10.1136/EWJM.176.1.20","url":null,"abstract":"Residents of developmental centers deserve care at the end of their lives that is consistent with their wishes. When their wishes are unknown, as is often the case, the care that they receive should be in their best interests. One way of determining whether care is in a resident's best interests is to hold a formal discussion leading to a decision about end-of-life care, known as an “end-of-life decision.”1 We investigated the prevalence of end-of-life decisions in a modern developmental center. Our center provides long-term care, from youth to death, to 850 people with severe developmental disabilities, whose demographic features have previously been published.2 All residents are unmarried and childless; 20% have a family involved in their welfare decisions. The center's annual budget is $115 million, or $135,000 per resident.","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"5 1","pages":"20-2"},"PeriodicalIF":0.0,"publicationDate":"2002-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81934321","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Shaping America's health care professions: the dramatic rise of multiculturalism.","authors":"Bram B. Briggance, N. Burke","doi":"10.1136/EWJM.176.1.62","DOIUrl":"https://doi.org/10.1136/EWJM.176.1.62","url":null,"abstract":"Fifty years ago, for the question on the US census form, “What is your race?”, 89% of participants checked the box for “White,” 10% checked “Negro,” and 1% checked the box for the phrase “or what race?”1 Most experts agree that this census report is largely inaccurate because of the methods employed in its data collection. However, it provides a rough sketch of a United States that would be unrecognizable today. The racial and ethnic composition of the US population is changing at its most dramatic rate since the great wave of immigration at the turn of the 20th century. Persons neither white nor African American constitute almost 18% of the US population today, and this demographic change is escalating.2 Consider the following: The nonwhite US population will reach 32% by 2010 and 47.2% by 20502 Since 1990, the number of foreign-born residents has increased by 6 million and is currently about 25 million (9.3% of the general population)3 The United States adds 1 million immigrants to its population each year (70% legal, 30% illegal)2 Recent-immigrant and nonwhite populations have a birth rate 50% higher than that of the US white population3 By 2025, the Hispanic population of California will be about 33% greater than its white population4 The US Asian population is expected to grow almost 25% in the next decade4 It could be argued that the effect of America's evolution toward multiculturalism will outstrip all other social, economic, and technologic trends. The US health care system will not be exempt from these changes, and it is currently not prepared to manage this increase in racial and ethnic diversity. Our shifting demography threatens to expose the ways in which our nation's medical establishment has failed its nonwhite residents. Three primary criteria for the evaluation of any health care system are the overall health of the population it serves, the accessibility it provides, and the quality of care it delivers. By these standards, the US health care industry is failing its nonwhite communities.","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"72 1","pages":"62-4"},"PeriodicalIF":0.0,"publicationDate":"2002-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89520921","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Yes: it can be a delusional symptom of psychotic disorders.","authors":"A. Poussaint","doi":"10.1136/EWJM.176.1.4","DOIUrl":"https://doi.org/10.1136/EWJM.176.1.4","url":null,"abstract":"The American Psychiatric Association has never officially recognized extreme racism (as opposed to ordinary prejudice) as a mental health problem, although the issue was raised more than 30 years ago. After several racist killings in the civil rights era, a group of black psychiatrists sought to have extreme bigotry classified as a mental disorder. The association's officials rejected the recommendation, arguing that because so many Americans are racist, even extreme racism in this country is normative—a cultural problem rather than an indication of psychopathology. The psychiatric profession's primary index for diagnosing psychiatric symptoms, the Diagnostic and Statistical Manual of Mental Disorders (DSM), does not include racism, prejudice, or bigotry in its text or index.1 Therefore, there is currently no support for including extreme racism under any diagnostic category. This leads psychiatrists to think that it cannot and should not be treated in their patients. To continue perceiving extreme racism as normative and not pathologic is to lend it legitimacy. Clearly, anyone who scapegoats a whole group of people and seeks to eliminate them to resolve his or her internal conflicts meets criteria for a delusional disorder, a major psychiatric illness. Extreme racists' violence should be considered in the context of behavior described by Allport in The Nature of Prejudice.2 Allport's 5-point scale categorizes increasingly dangerous acts. It begins with verbal expression of antagonism, progresses to avoidance of members of disliked groups, then to active discrimination against them, to physical attack, and finally to extermination (lynchings, massacres, genocide). That fifth point on the scale, the acting out of extermination fantasies, is readily classifiable as delusional behavior. More recently, Sullaway and Dunbar used a prejudice rating scale to assess and describe levels of prejudice.3 They found associations between highly prejudiced people and other indicators of psychopathology. The subtype at the extreme end of their scale is a paranoid/delusional prejudice disorder. Using the DSM's structure of diagnostic criteria for delusional disorder,4(p329) I suggest the following subtype: Prejudice type: A delusion whose theme is that a group of individuals, who share a defining characteristic, in one's environment have a particular and unusual significance. These delusions are usually of a negative or pejorative nature, but also may be grandiose in content. When these delusions are extreme, the person may act out by attempting to harm, and even murder, members of the despised group(s). Extreme racist delusions can also occur as a major symptom in other psychotic disorders, such as schizophrenia and bipolar disorder. Persons suffering delusions usually have serious social dysfunction that impairs their ability to work with others and maintain employment. As a clinical psychiatrist, I have treated several patients who p","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"4 1","pages":"4"},"PeriodicalIF":0.0,"publicationDate":"2002-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"87118034","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Learning about bioterrorism and chemical warfare","authors":"Jena C. Berg, S. Chandrasoma, Isaac Yang, J. Lynch, A. Walling","doi":"10.1136/ewjm.176.1.58","DOIUrl":"https://doi.org/10.1136/ewjm.176.1.58","url":null,"abstract":"","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"32 1","pages":"58-59"},"PeriodicalIF":0.0,"publicationDate":"2002-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"87118844","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Management of uncomplicated urinary tract infections.","authors":"T. Jancel, Vicky Dudas","doi":"10.1136/EWJM.176.1.51","DOIUrl":"https://doi.org/10.1136/EWJM.176.1.51","url":null,"abstract":"Uncomplicated urinary tract infections are among the most frequently occurring infections in the United States, resulting in an estimated 8 million office visits and 1 million hospital admissions each year.1,2,3 Between 40% and 50% of women have reported having at least one urinary tract infection in their lives.4 Urinary tract infections can be classified by anatomic site of involvement into lower and upper urinary tract infections. Infections of the lower urinary tract include cystitis, urethritis, prostatitis, and epididymitis, and those of the upper urinary tract include pyelonephritis. Urinary tract infections may be further classified as complicated or uncomplicated. In women with a structurally and functionally normal urinary tract, cystitis and pyelonephritis are considered uncomplicated urinary tract infections. Urinary tract infections in men, elderly people, pregnant women, or patients who have an indwelling catheter or an anatomic or functional abnormality are considered complicated urinary tract infections. In this article, we outline the pharmacologic approach to the prevention and treatment of uncomplicated cystitis.","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"76 1","pages":"51-5"},"PeriodicalIF":0.0,"publicationDate":"2002-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86386479","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Health as a consumer product.","authors":"S. Chandrasoma","doi":"10.1136/EWJM.175.6.421","DOIUrl":"https://doi.org/10.1136/EWJM.175.6.421","url":null,"abstract":"","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"178 1","pages":"421-2; discussion 422-3"},"PeriodicalIF":0.0,"publicationDate":"2001-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82320527","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Genetic catastrophe: learn, then lay them to rest.","authors":"D. B. Hill","doi":"10.1136/EWJM.175.6.379-A","DOIUrl":"https://doi.org/10.1136/EWJM.175.6.379-A","url":null,"abstract":"To the editor, \u0000 \u0000To a certain extent, I agree with all of the points of view accompanying Camille Solyagua's photographs in the September 2001 issue of wjm, but I find the most resonant viewpoint is that of Kathleen Cranley Glass.1 In our culture, the bodies of the dead are laid to rest as a sign of respect and as a vehicle for closure. We even honor the family dog or cat in this way when they have been loved pets of children and ourselves. \u0000 \u0000As Glass pointed out, these infants were born to mothers and fathers—parents who felt pain and grief only barely imaginable by others, pain and grief that we are deliberately trained to suppress to maintain our clinical detachment. \u0000 \u0000As a physician, the exposure to these images is part of my education—in the event that I should deliver an infant with deformities of this nature, I need to remain calmly clinical as I deal with the situation and tend, not just to the infant (if viable), but also to the mother, who will be devastated. I hope I will be effective in helping to heal the emotional trauma she will face. \u0000 \u0000Let us learn from these unfortunates. We can photograph and scan and even autopsy them, but we must do so with care and reverence. And when we are done learning, I agree we should lay them to rest with all of the honor and sadness we would show for a “normal” stillborn infant.","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"225 1","pages":"379"},"PeriodicalIF":0.0,"publicationDate":"2001-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83276148","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}