1/11. poisoning-induced acute atraumatic compartment syndrome.Acute Atraumatic Compartment Syndrome (AACS) can be a potentially life and limb threatening complication of either drug abuse or medication injection. Prompt recognition followed by emergency fasciotomy is required to avoid permanent disability. A better understanding of the different clinical presentations may lead to improved outcomes through more expedient diagnosis and treatment. We describe five new cases of AACS caused by illicit drug abuse within the McGill University hospitals, with a review of all 102 similar patients previously documented in the literature between January 1970 and May 1997. The average age for all cases was 29 years, with 74% being male. The presence of edema, pain, tension, and skin changes were the most frequent symptoms and signs reported. There appear to be two distinct mechanisms of poisoning-induced AACS: (1) direct vasotoxicity and (2) limb compression caused by prolonged comatose state. Direct vasotoxicity is more likely to lead to eventual amputation, whereas prolonged limb compression is more likely to progress to systemic complications such as azotemia, hypotension, cardiac arrhythmia, and renal failure (crush syndrome). Long-term sequelae of motor loss, sensory disruption, and development of contracture were common in AACS of both causes. Because Compartment Syndrome is a surgical emergency, primary care and emergency physicians must have a high index of suspicion to promptly recognize and treat this problem.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/11. porphyria cutanea tarda and hiv: two cases associated with hepatitis c.hepatitis c virus (HCV) is a probable etiologic factor for the development of porphyria cutanea tarda (PCT), a photosensitive skin disease causing blistering, skin fragility, milia, and scarring. In a review of the literature, the hepatitis c status of patients coinfected with hiv and PCT was not known. Two patients with PCT who were seropositive for hiv and HCV are discussed herein. The appropriateness of performing porphyrin studies in patients diagnosed with hiv and photosensitivity and of prompting physicians to test for hiv and HCV infection in individuals who are diagnosed with PCT is discussed. Because hiv has been isolated from cutaneous blister fluid in patients with PCT and hiv, caregivers should be aware of the infection risk associated with the vesicles and erosions in these patients.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/11. ethics seminars: hiv testing, consent, and physician responsibilities.Emergency physicians constantly have multiple ethical obligations in the emergency department. They must understand these sometimes conflicting obligations and learn to prioritize. A case discussion is presented that exemplifies the conflict between patient privacy and society's right to know. Specific aspects of hiv testing and obtaining patient consent are presented. teaching physicians are encouraged to use such common cases for "ethics case discussion."- - - - - - - - - - ranking = 6keywords = physician (Clic here for more details about this article) |
4/11. Valve replacement in endocarditis: setting limits in noncompliant intravenous drug abusers.An intravenous (IV) drug abuser underwent repeated valve replacements because of recurrent infective endocarditis. Is it ethically permissible to withhold valve surgery in a recalcitrant, noncompliant IV drug abuser? We believe so, and in our analysis, discuss the principles of futility, rationing, personal responsibility, and justice. Because of her continued drug abuse, the patient is responsible and accountable for the medical consequences. The consequences are that physicians will not be able to provide her with beneficial treatments without disproportionate harm, and that society will no longer be able to provide resources for her treatment without unfairly jeopardizing the availability of resources for other members of society. Although valve surgery does not constitute futile treatment, maximizing and egalitarian principles of societal justice support the withholding of such an expensive intervention. The patient should be jointly evaluated by the physician, social worker, and psychiatrist. The medical team will emphasize patient compliance and willingness to undergo drug rehabilitation, and will offer the first valve replacement. The recidivist abuser with demonstrable non-compliance who sustains a second episode of endocarditis need not be offered another valve. To avoid bedside rationing, we recommend the formulation of such a policy by nations and professional bodies.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
5/11. Abuse of prescription buprenorphine, regulatory controls and the role of the primary physician.INTRODUCTION: buprenorphine is an opioid partial agonist approved in several countries for the treatment of opioid dependence. It was approved in singapore in 2002 for this indication, and is more widely available in the primary care setting and can be prescribed by all licensed physicians who have undergone designated training. There is limited literature addressing the risk of its illicit abuse via intravenous self-administration. CLINICAL PICTURE: We report 2 such cases of the abuse of prescription buprenorphine in the psychiatric consultation-liaison service of a general teaching hospital, the treatment approaches and outcomes. CONCLUSION: We also briefly review the indications, uses and abuses of buprenorphine in singapore, and as reported in other countries, and the roles of primary care physicians, in order to stimulate greater awareness and understanding among specialists and general practitioners, who would encounter these patients in various settings.- - - - - - - - - - ranking = 6keywords = physician (Clic here for more details about this article) |
6/11. syphilis. A new look at an old killer.Thirty-four-year-old George Talbot was admitted to your medical/surgical unit with deep vein thrombosis of his left leg, probably related to intravenous drug abuse. So it's no surprise that Mr. Talbot is receiving heparin IV. Today, however, you notice that his physician has prescribed one dose (2.4 million units) of benzathine penicillin IM. You're not sure why until you check the patient's lab work. Mr. Talbot's rapid plasma reagin (RPR) test was reactive. The physician is treating Mr. Talbot for syphilis.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
7/11. "Cotton fever": a benign febrile syndrome in intravenous drug abusers.Cotton fever is a benign, self-limited syndrome that may mimic sepsis in intravenous drug addicts. We present an illustrative case and a review of the literature. Serious illness such as pneumonia and infectious endocarditis must always be considered in febrile addicts. However, trivial illness accounts for 16% to 26% of such fevers. Recent evidence suggests that emergency physicians are able to diagnose trivial illness with 93% specificity in febrile adult drug addicts. Short-term observation units may be an alternative to hospital admission for febrile drug users with a presumptive diagnosis of trivial illness and in those in whom the diagnosis of cotton fever is entertained.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/11. AIDS and drug abuse: some aspects of psychiatric consultation.Current research in Buenos Aires shows that approximately 35 per cent of intravenous users are hiv positive. These patients have behaviour disorders. Usually they are sent from one specialist to another, which increases their anxiety that originated in their suspicion of a serious prognosis. They are listened to when they discuss their disease but not enough when they try to talk about themselves as people with doubts about their future. Unconsciously physicians are trying to avoid involvement in the anxiety of the patient by means of a referral to a psychiatric consultation. The psychiatrist must handle this situation as a crisis in the doctor-patient relationship (both need help) to preventing further acts, additional anxiety and psychotic reactions. These patients need strong support not only because of the seriousness of the disease but also because of the situation of abstinence. Global treatment of a patient should be unified and managed by a physician with psychological training or assessed by one liaison psychiatrist, trying to avoid any split in the health team.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
9/11. How to recognize adolescents at risk for hiv infection.hiv infection is a growing problem for primary care physicians in that the coming of adolescents to clinics for primary care may not clearly demark members of a high-risk group. Therefore, clinicians need to be familiar with the risk categories and question the patients as to high-risk activities in order to determine their risk for hiv infection. Adolescents may be at a higher risk for hiv, but may not bear manifestations of infection with hiv infection until later. Therefore, it would behoove clinicians to establish the serologic status of adolescents at risk in a timely fashion in order to offer counseling and manage the protean manifestations of hiv-related disease that may occur. counseling must also emphasize the importance of curtailing the high-risk activity so as to curb the spread of the infection.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/11. Spinal infections in the immunocompromised host.There is an increasing population of immunocompromised patients with hiv, IV drug abuse, organ transplantation, and long-term steroid treatment developing spinal infections. delayed diagnosis because of blunted host immune response and lack of outward signs and symptoms places the treating physician at a disadvantage in the treatment of this type of disease, which presents at a later stage of development. Immunocompromised patients are infected by a different group of pathogens than their healthier cohorts (e.g., pseudomonas, gram-negative bacteria and fungal infections) because their host defenses are diminished. osteomyelitis with or with out pyomyositis and epidural abscess may occur. The overriding symptom is back pain. radiculopathy, myelopathy, and sensory loss may accompany local pain and tenderness. Plain film radiography, CT scan, MR image, and bone scan is invaluable in the diagnosis of these infections. The cornerstone of treatment is identification of the responsible pathogen, appropriate medical therapy, immobilization of the affected segment of the spine, and physical therapy to combat physical deconditioning. Psoas abscesses may require surgical debridement if they cannot be adequately drained by CT-guided percutaneous catheterization. Epidural abscesses with neurologic compromise require surgical drainage. Impingement of the spinal cord or cauda equina by collapsed osteomyelitic vertebral bodies requires surgical debridement by anterior vertebrectomy, with an autologous tricortical iliac crest strut and immobilization of the spine using external bracing or posterior instrumentation as dictated by the disease.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
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