Biomedical subjects
Publications and source records attributed to H D Kerr.
This case illustrates intravenous radiographic contrast material as an unusual and little known etiology of seizure. A brief review of the literature is provided in which the incidence of contrast induced seizures and the potential risk factors for their development are discussed.
A 51 year-old woman with a history of ureteral stenosis and calculi noted recurrence of severe left flank pain while undergoing a deep body massage using the Rolfing method. Displacement of her left ureteral double J stent was noted in the emergency department. The pain and associated incontinence resolved with restoration of the stent to its original position. Practitioners should be aware of this potential complication related to forceful massage pressures.
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OBJECTIVE: To describe the prevalence, degree, and types of hearing loss present in a group of older American veterans who had been prisoners of war of the Japanese. DESIGN: A descriptive study. SETTING: A Veterans Affairs university hospital. PARTICIPANTS: Seventy-five male veterans, mean age 68 (+/- 3.6) years. INTERVENTIONS: Hearing aids were prescribed for eight veterans. MEASUREMENTS: Subjects were examined, and pure tone air and bone conduction, speech reception threshold, and speech discrimination were determined. Results were compared with age- and sex-matched controls from the largest recent American population study of hearing loss. RESULTS: 95% of subjects had been imprisoned longer than 33 months. Starvation conditions (100%), head trauma (85%), and trauma-related loss of consciousness (23%) were commonly reported. A total of 73% complained of hearing loss, and 29% (22/75) dated its onset to captivity. Most of those with the worst losses in hearing and speech discrimination were found in this subgroup. When the entire group was compared with published age- and sex-matched controls from the Framingham Study, no significant differences were found. CONCLUSIONS: We advocate screening examinations and long-term follow-up of populations with similar histories of starvation, head trauma, and torture.
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Hoodoo is a folk belief system common among black Americans. Conjuration and rootwork are other terms used to describe this system which includes the casting of spells and witchcraft. This paper describes the black folk concept of 'white liver', an aspect of hoodoo which bears striking resemblance to AIDS. White liver refers to a condition characterized by sexual excess and a wasting to death of sexual partners. Although clearly antedating by many years the current AIDS epidemic, white liver is important as a contemporary black cultural entity that may be used to describe AIDS or to articulate a fear of AIDS.
Described is an elderly woman who developed gastrointestinal bleeding probably potentiated by the interaction of fluconazole with warfarin. Because varied clinical uses are being found for fluconazole, clinicians should be aware of this potential interaction.
Public outcry regarding unsafe interhospital patient transfers led to the passage of the COBRA Law of 1985. Since its implementation in 1986, the law has been sharply criticized for its sporadic enforcement, narrow focus, and lack of care provisions for the poor. We reviewed retrospectively the charts of all emergency department patients transferred from two Milwaukee private hospitals during two identical 6-month periods in 1985-1986 and 1988-1989. We compared demographic and clinical characteristics of the patients transferred during the two periods. The emergency departments cared for 15% of Milwaukee's emergency patient population and transferred 216 and 200 patients during each respective period. Uninsured transfers fell from 32% to 17% of the study populations. Although the proportion of the local population belonging to a health maintenance organization (HMO) did not change, transfer of HMO patients increased from 14% to 27%. Transfers to the area's various tertiary care centers made up 21% and 35% of all transfers and were conducted without regard to insurance status. There was a fourfold increase in the use of the county's public assistance plan for emergency hospitalization of indigent patients at local hospitals. Although the number of uninsured patients transferred from the study hospitals decreased markedly, this decrease was counterbalanced by increased private hospital use of the county's emergency hospitalization plan for indigent patients. This successful plan bears further examination by health policy planners as an important model for the provision of emergency hospitalization for the indigent.
A man with Maffucci's syndrome and lifelong lymphedema in the right lower extremity had a lymphangiosarcoma in the same extremity. Despite amputation of the limb and radiotherapy, he died several months later of pulmonary metastases. Malignancies of vascular origin rarely have been reported in this syndrome. Our patient's features suggest that lymphedema may predispose patients with Maffucci's syndrome to the development of lymphangiosarcoma.
Nursing home residents are frequently transferred to hospital emergency departments. Delayed transfer may lead to poor outcomes. However, inappropriate transfer of the frail elderly may cause social and financial problems. We prospectively evaluated 221 consecutive ambulance transfers from community nursing homes to a VA emergency department. The objectives of the study were to describe the process and outcomes of transferred patients and to determine if alternative interventions were feasible. The results indicate that the problems of nearly half the study group could have been treated at the nursing home by a visiting physician with minimal medical equipment. Those admitted to the hospital (52%) were seriously ill, had prolonged lengths of stay (23.6 days), and had a high mortality rate (11%). Complex issues of physician reimbursement, proprietary nursing home budgeting, and day-to-day expediency appear to be involved in decisions to transport patients by ambulance to VA emergency departments.
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We prospectively studied all transfers from community hospitals to the Zablocki Veterans Administration Medical Center in Milwaukee (Wis) between May 28, 1986, and January 1, 1987. Transfers totaled 4.7% (311/6609) of acute-care admissions during the study period but accounted for 19.1% (39/204) of in-hospital deaths. The mortality rate for transferred patients who required Veterans Administration hospitalization was 12.5% (39/311) compared with 2.6% (165/6298) for all other admissions. At the time of transfer 59 patients (19%) were judged unstable by a modification of the APACHE II classification system, yet only 19 patients were cared for en route by a physician or a nurse. In addition to higher mortality, the transferred patients had a longer median length of stay than nontransferred patients (11 days vs 7 days).
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An unresolved question related to the practice of health maintenance organizations' (HMOs) controlling access to medical care is whether such screening of patients seeking emergency department treatment impairs efficient patient care or endangers patients. A preliminary study was undertaken to determine whether so-called gatekeeping of access to EDs was common practice. Medical directors of HMOs in 39 states and the District of Columbia were surveyed by a mail questionnaire to assess policies regarding ED access. There were 98 (80.3%) respondents to 122 questionnaires, representing 26% of all federally qualified HMOs in the United States. Of the 98 respondents, 90 (92%) used the distinctions "life-threatening" and "nonlife-threatening" in defining their ED access policies. In life-threatening situations, members were permitted to go to any hospital without calling the gatekeeper first. In nonlife-threatening situations 78 of 98 (80%) required that permission be obtained prior to an ED visit. Most required a telephone call; nonphysicians could act as gatekeepers in 46 of 78 (59%). Thirty-nine percent of the 98 respondents limited their members to using the EDs of certain hospitals only. Ninety-four of 98 (96%) reviewed all ED visits prior to making any payment. We discuss here the implications of these gatekeeping policies.
I have described a patient with scleroderma whose sex, age at onset of symptoms, and history of long-term intravenous use of cocaine suggest a possible causative role of cocaine in his disease.
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A retrospective review was made of all patients with the diagnosis of drug ingestion or overdose seen in an urban community hospital over 30 months. There were 133 episodes involving 129 patients. Of these, 104 (78%) were hospitalized, including 96 at the study hospital. Fifty-three patients (55%) were initially admitted to the intensive care unit, and 57 (59%) were cared for in the psychiatry unit at some time during their course. One patient died, and 21 others (15%) suffered adverse consequences, including airway compromise requiring intubation, aspiration, seizures, cardiopulmonary arrest, and significant arrhythmias. The treatment rendered was supportive only, with no patient requiring hemodialysis or hemoperfusion. Multiple drugs were involved in 31% of the overdoses. The most common agents were benzodiazepines (32%), tricyclic antidepressants (24%), and acetaminophen (20%). A history of drug ingestion was obtained in 94% of patients. Based on subsequent drug level and drug screen testing, the history was judged accurate in 71% and inaccurate in 29%. The problems confronting hospitals that care for relatively few overdose patients but in a consistent pattern are discussed.