Biomedical subjects
Publications and source records attributed to Richard Shih.
Hydrocolpos is the accumulation of blood behind an imperforate hymen. Patients often present in early adolescence with cyclic abdominal pain. We present the case of an elite gymnast who, after 6 months of symptoms and a series of incorrect diagnoses, was diagnosed with hydrocolpos. It is likely that the patient's extraordinary training regimen contributed to the difficulty in diagnosis.
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We present a case of an elderly woman who presented with neck pain, low-grade fever, bandemia, and a massively elevated erythrocyte sedimentation rate (ESR) who had a cervical epidural abscess. We believe that the selective use of ESR assisted in narrowing the differential diagnosis, as the patient had no neurological deficits and no predisposing factors such as distal infection, immunosuppression, trauma, or recent surgery. Furthermore, in the literature, an elevated ESR is consistently found in patients with epidural abscesses, whereas clinical findings such as fever, leukocytosis, and neurological deficits are only variably present.
Ginkgo biloba, an extract of the ginkgo tree, may prevent or lessen symptoms of acute mountain sickness in humans. The mechanism of this effect is poorly understood. One hypothesis is that ginkgo alters nitric oxide (NO) metabolism, possibly by scavenging NO or altering nitric oxide synthase expression and thereby lessening the vasodilatory effects of NO. To date, an effect of Ginkgo biloba on NO metabolism has not been demonstrated in humans. We measured exhaled nasal NO output in humans (n = 9) during normoxia and then during acute normobaric hypoxia (goal oxyhemoglobin saturation 75% to 85%) before and after administration of a standardized extract of Ginkgo biloba (120 mg twice daily for 5 days). Oxygen saturation, heart rate, and minute ventilation were similar before and after Ginkgo biloba administration. Exhaled nasal NO output was increased during normoxia following ginkgo (p < 0.02) and reduced during normobaric hypoxia both before (p < 0.02) and following (p < 0.003) ginkgo. Exhaled nasal NO output during normobaric hypoxia was lowest following ginkgo (p < 0.003). We conclude that Ginkgo biloba increases exhaled nasal NO output during normoxia and enhances reduced exhaled nasal NO output during normobaric hypoxia. Our results suggest that Ginkgo biloba may act to reduce AMS through an effect on NO metabolism.
This study examines the impact of the administration of physostigmine and of nasogastric evacuation of Jimsonweed seeds on intensive-care unit (ICU) use and the length of stay in the hospital after Jimsonweed poisoning. Clinical data for this retrospective study were gathered from records of consecutive patients treated for Jimsonweed poisoning from September to November 1997. Descriptive statistics, Fisher's exact test, and Student t-test were used to analyze important clinical and sociodemographic variables. There were 17 victims of the Jimsonweed ingestion epidemic, all of whom presented with an anticholinergic toxidrome 3 to 9 hours after ingestion. Reported quantities of seed ingestion ranged from a low of 7 seeds to as high as 200 seeds. Altered mentation, manifested by combative behavior, necessitated admission of 13 patients to the ICU. The administration of physostigmine did not reduce admissions to the ICU (P = 0.54) or reduce length of stay in the hospital (P = 0.45) compared with the use of benzodiazepines alone. Nasogastric lavage was performed in 14 (82%) and seeds were recovered in 8 (57%) of those lavaged. The successful removal of Jimsonweed seeds did not decrease ICU use rates (P = 0.68) or shorten length of stay in the hospital compared with not recovering seeds (P = 0.85). The use of physostigmine and the successful nasogastric lavage of Jimsonweed seeds did not result in decreased intensive-care use or shorter length of stay in the hospital for Jimsonweed-induced anticholinergic toxicity.
CASE REPORT: Peritoneal exposure to mercury has been rarely reported and long-term consequences of this type of exposure have not been documented. We report the clinical course of a patient who has survived almost eight years with a massive intraperitoneal load of mercury. She has suffered formication, pruritus, fatigue, irritiability, insomnia, alopecia, dizziness, a gait disturbance, loss of balance and multiple falls, abdominal pain, choking, and headaches. Two courses of chelation with dimercaptosuccinic acid using the standard protocol were undertaken, resulting in increased daily excretion, but without demonstrable objective or subjective benefit or lasting effect. She had multiple medical problems before the mercury intoxication, which complicates the attribution of all her problems to mercury intoxication. It is of particular interest that the patient survived and did not suffer any marked cognitive deterioration. She died in 2002 shortly after being diagnosed with lung cancer and declaring that she would fight it. Phasing out of mercury-weighted tubes is recommended.
The Outcome Project is a long-term initiative by which the Accreditation Council for Graduate Medical Education (ACGME) is increasing emphasis on educational outcomes in the evaluation of residency programs. The ACGME initiated the Outcome Project to "ensure and improve the quality of graduate medical education." In order to assist program directors in emergency medicine (EM) to begin complying with components of the ACGME Outcome Project, the Council of Residency Directors in Emergency Medicine (CORD-EM) convened a consensus conference in March 2002 in conjunction with several other EM organizations. The working group for the competency of Practice-based Learning and Improvement (PBL) defined the components of PBL as: 1) analyze and assess practice experience and perform practice-based improvement; 2) locate, appraise, and utilize scientific evidence related to the patient's health problems and the larger population from which they are drawn; 3) apply knowledge of study design and statistical methods to critically appraise the medical literature; 4) utilize information technology to enhance personal education and improve patient care; and 5) facilitate the learning of students, colleagues, and other health care professionals in EM principles and practice. Establishing resident portfolios is a preferred method to chronicle resident competence in PBL. Traditional global evaluation of resident performance is de-emphasized. Checklist evaluation is appropriate for assessing any competency that can be broken down into specific behaviors or actions. 360-degree evaluation may be used to assess teamwork, communication skills, management skills, and clinical decision making. Chart-stimulated recall and record review are additional evaluation methods that can be used to assess resident competency in PBL. Simulations and models, such as computer-based scenarios, may be ideal for low-frequency but critical procedures.