Training internists for the changing medical scene.
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Hospitals, Teaching↗
Biomedical subjects
M Karpf
Publications and source records attributed to M Karpf.
Micturition syncope. A reappraisal.
We prospectively studied 33 patients with micturition syncope. Of these, eight were young (mean age, 25 years), healthy individuals whose diagnostic evaluation gave normal findings. The remaining 25 patients were older (mean age, 60 years), and 16 were women. This group had an average of 3.8 acute and chronic illnesses per patient, and was taking 3.5 medications per patient. Physical examination disclosed orthostatic hypotension in 22 of these 25 patients. Therapy was directed at improving orthostasis. Over a mean of 15.3 months, no recurrent micturition syncope or sudden death occurred in the entire group. We conclude that there are two groups of patients with micturition syncope. A group consisting of young healthy men has been well described previously. Our larger group, however, consisted of older patients, more often women with multiple illnesses and the majority having orthostatic hypotension.
Adolescent↗
Community-based geriatric assessment.
A comprehensive review of the multidisciplinary functional assessment and treatment of 800 patients seen at a community-based geriatric assessment center was performed to profile clinical characteristics of patients attending such a program and to evaluate possible predictors of institutionalization. The most common problems addressed were senile dementia (46%), hypertension (31%), clinically significant depression (30%), and burdened caregiver (24%). More than 90% of patients were able to remain in the community after multidisciplinary treatment of their problems and marshalling of support services. The most potent predictors of institutionalization in rank order of predictive value were: falls or unstable gait, senile dementia, caregiver strain, lack of support services, and moderate to severe impairment of ability to perform activities of daily living (multiple R = 0.45; P = .001). Advantages and impediments to community-based assessment are discussed.
Activities of Daily Living↗
Divisions of general internal medicine: accomplishments and needs.
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Hospital Departments↗
A comparative trial of the clinical evaluation exercise.
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Attitude of Health Personnel↗
The effects of high-dose corticosteroids in patients with septic shock. A prospective, controlled study.
To determine whether corticosteroids are efficacious in severe septic shock, we conducted a prospective study of 59 patients randomly assigned to a methylprednisolone, dexamethasone, or control group. Patients were treated 17.5 +/- 5.4 hours (mean +/- S.E.M.) after the onset of shock, and 55 patients required vasopressor agents. Early in the hospital course, reversal of shock was more likely in patients who received corticosteroids than in those who did not. Four (19 per cent) of 21 methylprednisolone-treated, 7 (32 per cent) of 22 dexamethasone-treated, and none of 16 control patients had reversal of shock 24 hours after drug administration (corticosteroid groups vs. control group, P less than 0.05). Patients treated with corticosteroids within four hours after the onset of shock had a higher incidence of shock reversal (P less than 0.05). At 133 hours after drug administration, 17 (40 per cent) of 43 corticosteroid-treated patients had died, and 11 (69 per cent) of 16 control patients had died (P less than 0.05). However, these differences in reversal of shock and survival disappeared later in the course. Overall, 16 (76 per cent) of 21 patients receiving methylprednisolone, 17 (77 per cent) of 22 patients receiving dexamethasone, and 11 (69 per cent) of 16 controls in the hospital died. We conclude that corticosteroids do not improve the overall survival of patients with severe, late septic shock but may be helpful early in the course and in certain subgroups of patients.
Adolescent↗
Deep venous thrombosis of the upper extremity five years experience at a university hospital.
All patients with deep vein thrombosis of the arm seen at one University Hospital over a 5 year period were reviewed. The 17 cases could be divided into distinct patient groups. The first group (primary thrombosis) consisted of 7 patients primarily healthy young males (mean age 23) who had vocations or avocations which involved vigorous physical activity of the arms. The 10 patients with secondary thrombosis tended to be older (mean age 47.3) and to be ill or hospitalized at the time of onset of their illness. Followup information could be obtained in 9 of the cases and 7 of these patients had persistence in their symptoms consisting of residual discomfort and edema of the involved arm especially after exercise. None of the patients treated with anticoagulation were asymptomatic. The only patients who were symptomatic were one patient who received streptokinase and another who underwent thrombectomy. Three illustrative case studies are included.
Adolescent↗
Issues in evaluating patients with syncope.
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Electrocardiography↗
A prospective evaluation and follow-up of patients with syncope.
We prospectively evaluated and followed 204 patients with syncope to determine how often a cause of syncope could be established and to define the prognosis of such patients. A cardiovascular cause was established in 53 patients and a noncardiovascular cause in 54. The cause remained unknown in 97 patients. At 12 months, the overall mortality was 14 +/- 2.5 per cent. The mortality rate (30 +/- 6.7 per cent) in patients with a cardiovascular cause of syncope was significantly higher than the rate (12 +/- 4.4 per cent) in patients with a noncardiovascular cause (P = 0.02) and the rate (6.4 +/- 2.8 per cent) in patients with syncope of unknown origin (P less than 0.0001). The incidence of sudden death was 24 +/- 6.6 per cent in patients with a cardiovascular cause, as compared with 4 +/- 2.7 per cent in patients with a noncardiovascular cause (P = 0.005) and 3 +/- 1.8 per cent in patients with syncope of unknown origin (P = 0.0002). Patients with syncope can be separated into diagnostic categories that have prognostic importance. Patients with a cardiovascular cause have a strikingly higher incidence of sudden death than patients with a noncardiovascular or unknown cause.
Adolescent↗
Abdominal computed tomography. Comparison of the usefulness of goal-directed v non-goal-directed studies.
We reviewed the indications for 210 consecutive abdominal computed tomography (CT) scans. One-hundred sixty-six CT scans were done in a goal-directed fashion, whereas 44 were non-goal-directed as part of the evaluation of non-specific abdominal pain, fever, or weight loss. Forty-three percent of CT scans done in a goal-directed fashion revealed new significant information as opposed to only 2% of non-goal-directed studies. Sixteen percent of goal-directed CT scans were normal as opposed to 41% of non-goal-directed CT scans. In at least 16% of cases, abdominal CT scans revealed data confirmatory of information obtained by other modalities. We conclude that abdominal CT scanning used in a non-goal-directed fashion is rarely helpful; however, goal-directed scanning often yields important information.
Body Weight↗
Pneumonia and multiple lung abscesses caused by dual infection with Legionella micdadei and Legionella pneumophila.
An immunocompromised patient developed pneumonia in which both Legionella micdadei and L. pneumophila, serogroup 6, were isolated from transtracheal aspirates in the absence of any other bacteria. Unusual features included the development of disseminated intravascular coagulation and multiple pulmonary abscesses during treatment with erythromycin, and relapse of the legionellosis after extended therapy with both erythromycin and rifampin, which was heralded by septic shock. Because simultaneous infection with two distinct species of Legionella occurs, concurrent increases in antibody titer to more than one Legionella may, in some instances, reflect multiple infection rather than cross-reacting antibody.
Adult↗
Syncope in the elderly: a pragmatic approach.
Carotid massage should be performed in elderly patients only if other diagnostic studies have not been helpful, since in rare instances, transient and permanent neurologic deficits have been precipitated by this maneuver. Patients with auscultatory findings of cardiovascular disease should certainly undergo further evaluation with appropriate studies such as echocardiography, stress testing, or cardiac catheterization.
Aged↗
Syncope of unknown origin. The need for a more cost-effective approach to its diagnosis evaluation.
The records of 121 patients hospitalized in Presbyterian-University Hospital, Pittsburgh, during 1976 to 1980 for syncope of unknown origin were reviewed. The were 58 men and 63 women, whose mean age was 63.1 years. Cardiac monitoring in 67 patients showed abnormalities in seven patients, considered diagnostic of the cause of syncope. In 13 patients with electrophysiologic studies, four patients had abnormal results, suggesting a probable cause for the syncope. Cardiac catheterization in 14 patients showed significant findings that demonstrated the cause of syncope in three patients. Glucose tolerance tests in 37 patients, head computed tomographic scans in 39 patients, radionuclide brain scans in 15 patients, lumbar punctures in 22 patients, and skull roentgenograms in 46 patients did not aid in the diagnosis of the cause of syncope in any patient. In 67 patients, EEGs produced abnormal results in 26, but the role of EEGs in the diagnostic workup of syncope could not be completely defined. The definitive cause for syncope was diagnosed in only 13 of 121 patients, with an average hospitalization of nine days and an average cost of $2,463 per patient. These findings suggest that an extensive evaluation of syncope is cost--ineffective and that prospective goal-directed approaches need to be developed.
Brain↗
Anisakiasis: nematode infestation producing small-bowel obstruction.
A case of small-bowel obstruction occurred secondary to an uncommon parasitic disease, anisakiasis. Intestinal obstruction is a rare manifestation of this disease. Anisakiasis may be seen initially with nausea and vomiting or may mimic acute appendicitis or Crohn's disease. The predisposing factor in all cases is the ingestion of raw fish, and the disease is preventable by cooking fish at greater than 60 degrees C for a short time or by freezing at less than -20 degrees C for more than 24 hours. Anisakiasis should be considered in the differential diagnosis of small-bowel obstruction in patients whose diet includes raw fish.
Adult↗
Impact of attending level supervision of the emergency department experience.
Medical experiences encountered in the activities of an emergency department are important for the development of a well-trained internist. Therefore, a rotation in the emergency department must remain an integral part of any program in internal medicine. At the University of Pittsburgh, faculty members from both the internal medicine and emergency medicine departments worked together in order to develop the emergency department to its fullest capacity as part of a broad educational program. The faculty attendings provide supervision, immediately available consultation, and an on-going curriculum, including daily lectures and chart review. The results of their programmatic change have been the following: 1) enthusiasm and satisfaction on the part of the housestaff; 2) a 20+ increase in admissions to the hospital from the emergency department; 3) decreased utilization of the observation unit; and 4) fewer patients leaving without being examined.
Ambulatory Care↗
Development of a division of general medicine in a department of internal medicine.
Complex social and economic pressures have initiated a perceptible shift in the composition of departments of medicine, which are now required to provide a more balanced faculty effort in the areas of patient care, teaching, and research. This report describes the development and diverse roles of a Division of General Medicine in the Department of Medicine of the University of Pittsburgh School of Medicine. The division members are academically oriented general internists adhering to the principles of scholarship found in traditional subspecialty divisions. The division members play key roles in the organization of the student and resident teaching programs in general internal medicine. Patient care and research activities, fiscal organization, and plans and problems in the area of promotion and tenure are discussed. Since divisions of general medicine seem destined to become integral parts of most, if not all, departments of medicine, the division described in this report may serve as a model for other institutions.
Faculty, Medical↗
Ventricular arrhythmias during Swan-Ganz catheterization of the critically ill.
The incidence of ventricular arrhythmias in critically-ill patients during bedside right-sided heart catheterization with a flow-directed balloon-tipped catheter was determined. Twenty-nine of 60 catheterizations (48 percent) were associated with premature ventricular contractions and 20 (33 percent) were associated with ventricular tachycardia. Two patients required antiarrhythmic therapy or a precordial thump to convert ventricular tachycardia. One patient developed ventricular tachycardia and fibrillation and died. Serious catheter-induced arrhythmias, including sustained ventricular tachycardia, may occur during Swan-Ganz catheterization of the critically ill.
Arrhythmias, Cardiac↗
Induction of lactic acidosis with intravenous diazepam in a patient with tetanus.
A patient with tetanus was treated with high-dose intravenous (IV) diazepam for control of muscular spasms. As the spasms were controlled with diazepam, lactic acidosis developed. The condition resolved on discontinuation of diazepam therapy and recurred with reinstitution of the drug. To our knowledge, lactic acidosis previously has not been associated with the use of high-dose IV diazepam.
Acidosis↗