James B. Reuler

Current concepts: Wernicke's encephalopathy

Despite its description over a century ago, Wernickes encephalopathy continues to be underrecognized in both alcoholic and nonalcoholic populations. Recent studies suggest that Wernickes encephal...

Hypothermia: Pathophysiology, Clinical Settings, and Management

Hypothermia, defined as a core temperature less than 35 degrees C, is frequently not recognized, in part because of the inadequacy of standard thermometers. This entity has multiple causes and unique pathophysiologic consequences that complicate diagnosis and treatment. Understanding of the physiology of thermoregulation is important in light of recent advances in therapy using core rewarming. Pathophysiology, etiology and management of the hypothermia syndrome are reviewed.

The pressure sore: Pathophysiology and principles of management

The pressure sore is a common clinical problem, although its pathophysiology and management are poorly appreciated by many physicians. The impact of these lesions in terms of patient morbidity and rehabilitation, and health care expenditures is great. Shearing forces, friction and moisture, as well as pressure, contribute to the development of these sores. This paper reviews the clinical settings, causative factors, complications, and principles of prevention and management of the pressure sore. Early surgical consultation is important, because of the deceptive nature and multiple sequelae of these wounds.

The Chronic Pain Syndrome: Misconceptions and Management

The management of chronic pain is a universal and vexing problem for physicians. Literature indicates that health care providers have a poor understanding of basic concepts relating to pain, which leads to frustration for the physician and inadequate relief for the patient. This paper addresses misconceptions about organic versus functional pain, discusses placebos and administration of narcotic analgesics, and outlines therapeutic alternatives. Emphasis is on distinguishing chronic pain of benign origin from that secondary to malignancy as an individual treatment plan is formulated.

Outpatients' attitudes and understanding regarding living wills.

Objective: To assess outpatients’ attitudes toward and understanding of a standard living will.Design: Survey using a self-administered questionnaire that patients completed after they had read a sample living will.Setting: General medicine clinic of a Department of Veterans Affairs medical center.Patients: Two hundred fourteen patients (85% of those approached) attending a continuity care clinic appointment. Eighty-seven percent were men; mean age was 60 years.Measurements and main results: Patients’ attitudes toward living wills, understanding of the terminology contained in living wills, desire to discuss living wills with their doctors, and desire to prepare a living will.Results: Seventy-two percent of the patients had prior knowledge of living wills, though only 53% had discussed the topic with family members and only 14% with physicians. Half felt that the living will terminology should be simplified, and 55% were unable to identify the correct definition for at least one commonly used term. Desire to prepare a living will was positively associated with better understanding of the sample document and previous knowledge of and exposure to living wills, and was negatively associated with concern about its use and revocability (all p<0.001). Patients who reported poor understanding of the living will were more likely to want to discuss the topic with a physician (p<0.01).Conclusions: In this ambulatory patient population attitudes toward living wills were influenced by knowledge and understanding of these documents. Primary care physicians and institutions should develop patient education strategies that enhance understanding of advance directives.

Management of suspected temporal arteritis: A decision analysis

Management strategies for suspected temporal arteritis range from bilateral temporal artery biopsy to empiric corticosteroid therapy. A decision analysis of the clinical situation was constructed, and a sensitivity analysis for varying prevalences of temporal arteritis was used to calculate costs for different management strategies. Conclusions suggested by the analysis include the following: (1) due to the high cost of blindness, suspicion of disease must be low (< 1.4070) not to biopsy; (2) at high suspicion of disease (> 30Vo), empiric steroids are the cheapest management; (3) when diagnostic procedures are indicated, bilateral biopsy is the cheapest initial diagnostic procedure; and (4) if unilateral biopsy is negative, a second biopsy is always cost effective. (Med Decis Making 3:63-68, 1983).

Cost analysis of a needle stick protocol.

A protocol for prophylaxis against hepatitis B in an employee health program was analyzed for cost-effectiveness. Over a three-year period, 302 needle-stick incidents involving 282 employees and 234 patients were reported. No new HBsAg-positive patients or employees were identified, and 6% of employees were found to be anti-HBs positive. Given the low prevalence rate of hepatitis B infection in our population, cost analysis supported curtailment of serologic screening for routine needle-stick exposures.

Back pain and epidural spinal cord compression

The physician must have a high index of suspicion to detect SCC early in patients with malignancy. Back pain is the first symptom in almost all patients, and the diagnosis should be considered for all older patients with back pain. Asking about back pain should be a routine part of the review of systems, especially for patients with known malignancies. Clinically, it is impossible to tell whether or not a patient who has back pain and cancer has epidural SCC. Patients may be stratified as to the likelihood of SCC using the history and physical examination, but the diagnosis relies on radiographic visualization of the spinal cord. It may be acceptable to closely follow patients with normal neurologic examinations and normal plain films, but even this is controversial and includes only a minority of patients. Myelography remains the test of choice. MRI will play an increasingly important role in the future, but has not yet been systematically evaluated. The best therapeutic approach is not clear, but standard treatment is only about 50% effective in all cases. At present, radiation therapy is the treatment of choice for many patients, in particular those who are ambulatory at diagnosis. Anterior resection with vertebral body reconstruction is an exciting approach and may substantially improve the prognosis for patients who are paraparetic or paraplegic. It is important to attempt to choose for each patient the diagnostic and therapeutic options offering the best chance for comfort and preservation of function. The decision of how or even whether to treat is multifactorial and is more complicated than the determination of simply whether or not compression is present.(ABSTRACT TRUNCATED AT 250 WORDS)

Uncommon headaches: Diagnosis and treatment

SummaryHeadaches associated with exercise, cough, and sexual activity may present a diagnostic challenge in the emergency room or primary care provider’s office. The majority of these patients have no underlying intra-cranial pathologic condition and have a good prognosis. However, new onset of these types of headache, with or without accompanying neurologic deficit, is an indication to exclude life-threatening conditions such as subarachnoid bleeding with neuroimaging and CSF examination. Since the pathophysiology is poorly understood, derstood, treatment choices are limited. Further research is needed to elucidate the pathophysiologic mechanisms of these uncommon headaches and to assess the cost — effectiveness of various diagnostic and follow-up strategies.

Computed tomography in cerebral malignant disease.

Excerpt To the editor: In Dr. Weisbergs recent comprehensive review of computed tomography (CT)(1), two areas were not addressed in regard to malignant disease—leptomeningeal carcinomatosis and pr...