1/11. Supraesophageal complications of gastroesophageal reflux.Supraesophageal complications of GERD have become more commonly recognized or suspected by physicians. However, the direct association between these complications and GERD has often been difficult, if not impossible, to establish. Furthermore, the majority of patients with suspected supraesophageal complications of GERD do not have either the characteristic symptoms of heartburn and regurgitation or the definitive findings of esophageal inflammation, which would help reinforce the suspicion of a connection between the supraesophageal complications and GERD. Frequent acid reflux has been shown in patients with various bron-chopulmonary, laryngopharyngeal, or oral cavity disorders. GERD is one of the most common gastrointestinal complaints in the population. It is possible that the supraesophageal problems and acid reflux are mutually independent disorders that occur in the same person. The suspected mechanisms of GERD-related supraesophageal complications appear to be directed through two pathways: by a vagal reflex between the esophagus and tracheobronchial tree triggered by acid reflux or by microaspiration that causes contact damage to mucosal surfaces. The most useful diagnostic modality available to the clinician to aid in the diagnosis of supraesophageal GERD complications is the ambulatory pH recording technique. However, the sensitivity and specificity of this test for recording esophageal or pharyngeal acid reflux events has been critically challenged. Despite the many clinical studies that support the theory that GER has a role in suspected supraesophageal complications, only 1 long-term prospective controlled study of a large group of patients with asthma has shown the positive effects of the elimination of acid reflux. With the focus now on "outcomes medicine," there is a serious need for appropriately designed, controlled studies to answer the many questions surrounding a cause-and-effect association between acid reflux and supraesophageal disorders. Because of the lack of convincing proof between acid reflux and suspected supraesophageal complications, the physician must resort to an intent-to-treat strategy as both a primary therapy and a diagnostic trial. High-dose PPI therapy for prolonged periods is the recognized conservative therapy. Operative therapy (i.e., fundoplication operation) is the procedure of choice when overt regurgitation occurs or when medical therapy, although successful, is not practical for long periods. Controlled, well-designed clinical trials and more sophisticated techniques to measure and quantify acid reflux are crucial in the future to help determine which patients with suspected supraesophageal complications actually have acid reflux as a primary cause. The medical community needs to be alerted to the possibility of an association between GERD and supra-esophageal complications so that patients with a GERD-related complication will be recognized and effectively treated.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/11. Identifying and managing adverse environmental health effects: 2. Outdoor air pollution.air pollution contributes to preventable illness and death. Subgroups of patients who appear to be more sensitive to the effects of air pollution include young children, the elderly and people with existing chronic cardiac and respiratory disease such as chronic obstructive pulmonary disease and asthma. It is unclear whether air pollution contributes to the development of asthma, but it does trigger asthma episodes. physicians are in a position to identify patients at particular risk of health effects from air pollution exposure and to suggest timely and appropriate actions that these patients can take to protect themselves. A simple tool that uses the CH2OPD2 mnemonic (Community, Home, hobbies, Occupation, Personal habits, diet and Drugs) can help physicians take patients' environmental exposure histories to assess those who may be at risk. As public health advocates, physicians contribute to the primary prevention of illness and death related to air pollution in the population. In this article we review the origins of air pollutants, the pathophysiology of health effects, the burden of illness and the clinical implications of smog exposure using the illustrative case of an adolescent patient with asthma.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/11. A 55-year-old mechanically ventilated male requiring aeromedical evacuation.Objective: To present a case that illustrates the problems unique to transporting a mechanically ventilated patient by air. A 55-year-old mechanically ventilated male with guillain-barre syndrome, a condition with respiratory effects often similar to those of traumatic brain injury, required air transport from Walter Reed Army Medical Center in washington, DC, to a hospital in nevada. A medical team, including one physician, one nurse, and one respiratory therapist, accompanied the patient. This team was not trained in air travel and its unique risks. To complete the mission they had to rapidly familiarize themselves with the specific risks of air travel and the precautions that should be taken. This case is presented to illustrate these risks and what can be done during flight to minimize them.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
4/11. Angioneurotic edema of the upper airways and antihypertensive therapy.Angioneurotic edema is a non-pitting edema which is usually limited to the skin and the mucous membranes of the face and upper aerodigestive tract. The risk of acute upper airway obstruction makes angioneurotic edema a concern for emergency room physicians, internists and otolaryngologists because prompt recognition of the condition and immediate institution of therapy is essential for proper airway management. Angiotensin-converting enzyme (ACE) inhibitors have recently been associated with angioneurotic edema, the probable link being the reduction in angiotensin ii and the potentiation of bradykinin, resulting in vasodilatation, increased vascular permeability and angioedema. We report four cases of acquired angioneurotic edema, which were probably related to ACE inhibitor use. These cases are discussed, including a review of the literature, methods of diagnosis, pathophysiology and treatment of angioedema. Care should be taken when antihypertensive ACE inhibitor treatments are started and patients should be warned of the potential risk of angioneurotic edema.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
5/11. Chlorine inhalation toxicity from vapors generated by swimming pool chlorinator tablets.We have presented two cases of serious respiratory injury after brief exposure to vapors from solid chlorine compounds. We could find no previous reports of such accidents and, therefore, have related these cases to alert the medical community. We would recommend that physicians caring for children include warnings about these preparations in their routine counseling of parents.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
6/11. Acute symptoms of the aerodigestive tract caused by rapidly enlarging thyroid neoplasms.Two cases of rapidly enlarging tumors of the thyroid presenting with the sudden onset of symptoms referable to the aerodigestive tract are discussed. Although tumors of the thyroid are known to produce dysfunction of these structures, these cases are highly unusual, since in the vast majority of cases the onset and progression of these symptoms are insidious and rarely recognized by the patient or physician. The diagnostic workup and management of enlarging masses in this area is reviewed.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
7/11. Acute lower respiratory tract illness in illicit drug users--south carolina, 1995.On July 31, 1995, the south carolina Department of Health and Environmental Control was notified of a cluster of five patients with acute, severe lower respiratory illnesses among previously healthy residents of a small rural community in Berkeley County (1990 population: 128,776). All five patients were users of illicit drugs. This report summarizes the preliminary findings of an investigation initiated to describe the clinical features and epidemiology of this syndrome and to determine an etiology. Based on information about the five cases obtained from interviews with the patients and reviews of records, a case was defined as an unexplained acute, severe respiratory illness in a previously healthy person aged < 65 years characterized by shortness of breath and/or pleuritic pain with onset of symptoms during July 15-31. One additional case was identified by contacting local physicians, intensive-care units, and pulmonary and infectious disease specialists. No cases of similar acute respiratory illness were noted in household contacts of patients.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
8/11. Respiratory manifestations of gastroesophageal reflux in children.gastroesophageal reflux is often overlooked as both a cause and a complication of respiratory disease in children. The manifestations may be protean and may bear little clinical relationship to the gastrointestinal tract. However, a high index of suspicion for its potential role in unexplained respiratory symptoms may yield large benefits for the physician and patient alike.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
9/11. The Union Health Center: a working model of clinical care linked to preventive occupational health services.As health care provision in the united states shifts to primary care settings, it is vital that new models of occupational health services be developed that link clinical care to prevention. The model program described in this paper was developed at the Union Health Center (UHC), a comprehensive health care center supported by the International Ladies Garment Workers Union (now the Union of Needletrades, Industrial and Textile Employees) serving a population of approximately 50,000 primarily minority, female garment workers in new york city. The objective of this paper is to describe a model occupational medicine program in a union-based comprehensive health center linking accessible clinical care with primary and secondary disease prevention efforts. To assess the presence of symptoms suggestive of occupational disease, a health status questionnaire was administered to female workers attending the UHC for routine health maintenance. Based on the results of this survey, an occupational medicine clinic was developed that integrated direct clinical care with worker and employer education and workplace hazard abatement. To assess the success of this new approach, selected cases of sentinel health events were tracked and a chart review was conducted after 3 years of clinic operation. Prior to initiation of the occupational medicine clinic, 64% (648) of the workers surveyed reported symptoms indicative of occupational illnesses. However, only 42 (4%) reported having been told by a physician that they had an occupational illness and only 4 (.4%) reported having field a workers' compensation claim for an occupational disease. In the occupational medicine clinic established at the UHC, a health and safety specialist acts as a case manager, coordinating worker and employer education as well as workplace hazard abatement focused on disease prevention, ensuring that every case of occupational disease is treated as a potential sentinel health event. As examples of the success of this approach, index cases of rotator cuff tendonitis, lead poisoning, and formaldehyde overexposure in three patients and their preventative workplace follow-up, affecting approximately 150 workers at three worksites, are described. Work-related conditions diagnosed during the first 3 years of clinic operation included cumulative trauma disorders (141 cases), carpal tunnel syndrome (47 cases), low back disorders (33 cases), lead poisoning (20 cases), and respiratory disease (9 cases). This pilot project represents a new model for effective integration of clinical care and occupational disease prevention efforts within a primary care center. It could serve as a prototype for development of such services in other managed and primary care settings.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
10/11. giant cell arteritis and polymyalgia rheumatica: clues to early diagnosis.giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are closely related disorders found predominantly in older patients. These disorders, which are being recognized more frequently, are more common in women, in Caucasians, and in various geographic locations. Early recognition and treatment may prevent possible catastrophic consequences of GCA, such as blindness, stroke, or dissection of the aorta. Although diagnosis is fairly easy with the classic presentation, it may be missed when the patient presents with nonspecific constitutional symptoms. An increased awareness among primary care physicians will aid in the prevention of much of the morbidity and mortality related to these diseases.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
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