Team Physician or Athlete's Doctor?

My high school lost its final scheduled game of the season. When I say "my" high school, I mean the local high school where I've spent the past eight seasons on the sidelines and in the training room as the volunteer team physician.

Managing abrasions and lacerations

Abrasion and laceration management begins with controlling bleeding, assessing the wound site, and determining the patient's tetanus status. Abrasions are treated with thorough irrigation, a topical antibacterial agent, and an appropriate dressing. Laceration treatment includes anesthesia use and wound cleaning, suturing under sterile conditions, application of an appropriate dressing, and timely follow-up. Cyanoacrylate skin adhesives are a promising alternative to suturing for some wounds. Guidelines for return-to-play decisions are included.

Suture substitutes: using skin adhesives

Cyanoacrylate adhesives offer an attractive alternative to the use of sutures for closing lacerations, especially in sports medicine. Skin adhesives take less time to apply and cause less pain than suturing, and they require no dressing and no needle use-advantages that have obvious value in athletic settings. Further, studies (1,2) indicate that the cost of using tissue adhesives may be only 20% of that of suturing.

Optional introns in mitochondrial DNA of Podospora anserina are the primary source of observed size polymorphisms

The significant differences in mitochondrial genome size among seven races (B, E, M, T, U, W, and Y) of Podospora anserina have been found to be primarily due to the presence and/or absence of introns, including four introns not previously known to be optional. Information from physical mapping of races M and T, and sequence data from races A and s, was used to identify regions likely to contain insertions or deletions, which were then characterized using PCR and sequence analysis. Newly confirmed optional introns are the first intron of the large ribosomal RNA (LSUr1), the single intron of NADH dehydrogenase subunit 3 (ND3i1), the single intron in ATPase subunit 6 (ATPase6), and the fifth intron of cytochrome oxidase subunit I (COIi5). We have also found that race M exists in two forms as determined by mitochondrial DNA. These results bring to nine (including races A and s) the number of races characterized by mitochondrial intron content with a total of six known optional introns and one optional insertion. Eight of the nine races contain a distinct set of introns, providing a more reliable means for identification and comparison. The identification of optional mitochondrial introns in P. anserina may have evolutionary implications regarding the transfer and/or mobility of these introns.

Social workers' knowledge of and experience with sexual exploitation by psychotherapists

A survey of licensed social workers in Texas using self-administered questionnaires revealed that, during the previous 12 months, 17 percent had worked with at least one victim of sexual exploitation by a psychotherapist. Social workers licensed as advanced clinical practitioners, licensed social workers with master's degrees, and those working in private practice were most likely to have worked with a victim of such sexual exploitation. Most respondents were not familiar with the provisions of new Texas legislation concerning sexual exploitation by psychotherapists, including definitions and reporting requirements. The majority indicated they would be interested in additional training.

A multicenter, randomized study comparing the efficacy and safety of intravenous and/or oral levofloxacin versus ceftriaxone and/or cefuroxime axetil in treatment of adults with community-acquired pneumonia

Five hundred ninety patients were enrolled in a prospective, multicenter, randomized trial comparing the efficacy and safety of 7 to 14 days of levofloxacin treatment with that of ceftriaxone and/or cefuroxime axetil in the management of community-acquired pneumonia in adults. Patients received either intravenous and/or oral levofloxacin (500 mg once daily) or the comparative agents, parenteral ceftriaxone (1 to 2 g once to twice daily) and/or oral cefuroxime axetil (500 mg twice daily). Erythromycin or doxycycline could be added to the comparator arm at the investigator's discretion. The decision to use an intravenous or oral antimicrobial agent for initial therapy was made by the investigator. Clinical and microbiological evaluations were completed at the baseline, during treatment, 5 to 7 days posttherapy, and 3 to 4 weeks posttherapy. Four hundred fifty-six patients (226 given levofloxacin and 230 administered ceftriaxone and/or cefuroxime axetil) were evaluable for clinical efficacy. Streptococcus pneumoniae and Haemophilus influenzae were isolated in 15 and 12%, respectively, of clinically evaluable patients. One hundred fifty atypical pathogens were identified: 101 were Chlamydia pneumoniae, 41 were Mycoplasma pneumoniae, and 8 were Legionella pneumophila. Clinical success at 5 to 7 days posttherapy was superior for the levofloxacin group (96%) compared with the ceftriaxone and/or cefuroxime axetil group (90%) (95% confidence interval [CI] of -10.7 to -1.3). Among patients with typical respiratory pathogens who were evaluable for microbiological efficacy, the overall bacteriologic eradication rates were superior for levofloxacin (98%) compared with the ceftriaxone and/or cefuroxime axetil group (85%) (95% CI of -21.6 to -4.8). Levofloxacin eradicated 100% of the most frequently reported respiratory pathogens (i.e., H. influenzae and S. pneumoniae) and provided a >98% clinical success rate in patients with atypical pathogens. Both levofloxacin and ceftriaxone-cefuroxime axetil eradicated 100% of the S. pneumoniae cells detected in blood culture. Drug-related adverse events were reported in 5.8% of patients receiving levofloxacin and in 8.5% of patients administered ceftriaxone and/or cefuroxime axetil. Gastrointestinal and central and peripheral nervous system adverse events were the most common events reported in each treatment group. In conclusion, these results demonstrate that treatment with levofloxacin is superior to ceftriaxone and/or cefuroxime axetil therapy in the management of community-acquired pneumonia in adults.

Variability of the refractive state: meridional profiles and uniform variation

Variation of the refractive state as measured with autorefraction is the result of many factors which need to be considered if optometry is to develop a more complete understanding of the behavior of the visual process. Various methods can be applied to develop such an understanding including scatter plots, meridional profiles of variance-covariance, and graphs of uniform variation. These methods are used, in this paper, to investigate some results for autorefraction from a sample of 106 university students studying optometry. Some of the eyes in the sample display variation, some or all of whose characteristics are the same in all meridians of the eye. Such eyes are said to exhibit refractive variation that is partially or completely uniform across the meridians of the eye. Most eyes, however, show variation which appears to depart from uniformity. The typical eye in the sample appears to exhibit variation that is mainly spherical in character and of a small magnitude in keeping with the view that the accommodative system mostly is responsible for this variation. Nevertheless, there is an astigmatic component to the variation. The mean variance-covariance matrices for the right and left eyes are presented.

Variation during autorefraction: influence of two different target types

An investigation was performed on seven subjects of varying ages in order to determine the influence of two different target types on autorefractor results. A single autorefractor capable of presenting two different targets was used. Multivariate statistical methods which only recently have become available in optometry are used to illustrate graphically the results obtained and formal hypothesis tests further demonstrate that most of the eyes in the sample display similar variation or behaviour with both targets. The mean refractive state likewise is not significantly different for both targets for five of the seven eyes at a 99% confidence level. Departures from multivariate normality (such as resulting from outliers) are shown to be of great importance in order to reach appropriate decisions with respect to target influence on autorefractor measurements and an example is provided to illustrate this point. In the absence of departures from normality it is believed that this study exhibits only weak evidence for differences in variation or mean refractive state with the different target types.

Predictive validity of Marlatt's relapse taxonomy versus a more general relapse code

Marlatt's system for classifying relapses involves integrating information about the context of a relapse into a judgment about the most critical aspects of the situation. Constraints in this taxonomy, however, may limit its validity. On a sample of 300 subjects drawn from six treatment facilities, we compared the predictive validity of Marlatt's taxonomy with that of a coding scheme with fewer constraints. Marlatt's taxonomy does not significantly predict drinking outcome, nor does it predict time to relapse. There is weak evidence, however, that under some circumstances Marlatt's taxonomy can predict the type of relapse subsequently observed. The alternative coding system also does not seem useful for predicting drinking outcome, although a possible association was found between internal attribution and time to return to heavy drinking. The alternative system does seem to be able to detect repetitive aspects of subsequent relapse situations; lack of social interactions, family setting, anxiety and depression were most likely to repeat. It may be useful to consider these relapse attributes in treatment planning. The minimal predictive validity for both the Marlatt and the alternative relapse code may be due to weaknesses in the relatively unstructured interview used to gather the data, or to failure to assess the most critical dimensions relating to subsequent relapse.

The reliability of Marlatt's taxonomy for classifying relapses

Marlatt's focus on the relapse situation has had a major impact upon research and clinical practice in treating addictions. One component of his work was the development of a taxonomy for classifying precipitants of relapse. This taxonomy has been incorporated into the nomenclature of clinicians and clinical researchers as part of an explanatory framework for understanding relapses. Despite the taxonomy's influence it has never been examined for the reliability of its use across research studies. The present study compared the reliability of independent classifications of 149 relapse episodes by trained raters at three research laboratories. Despite considerable across-laboratory training, reliability was found to be inconsistent for research purposes. It is concluded that comparability of results based on Marlatt's relapse taxonomy across independent studies must be subject to question, and assumptions necessary for the aggregation of a knowledge base are not supported. Recommendations are offered for improving the reliability of the taxonomy and the methods used to collect taxonomy data. More generally, questions regarding the value of the specific relapse categories, as well as the overall taxonomy, are raised.

Gender differences in relapse situations

Gender differences in variables relating to alcohol treatment are receiving increased attention. Most reports indicate gender differences in both intrapersonal, interpersonal and environmental trans-situational variables that relate specifically to women's drinking. This study investigates gender differences in the immediate relapse situation itself. These differences are then examined in the context of trans-situational (i.e. across time) affective and cognitive variables and social support. This report is part of a larger study designed to replicate Marlatt's taxonomy of high risk situations for relapse, and to examine alternative methods of describing relapse situations. Three hundred subjects (169 men, 131 women) were recruited from six different inpatient and outpatient programs. Subjects were asked to identify their last relapse before entering the index treatment. Details of the drinking episode itself were also obtained, e.g. number of drinking days in episode, drinking to intoxication, presence of others. Measures of state and trait affect, expectancies, and social support were also collected. There were no gender differences in Marlatt's taxonomy, or in drinking topography during relapse. At baseline, women reported drinking less, and drinking less often than men. However, women drank to intoxication more often than men. Surprisingly, men relapsed alone more often than did women. Men and women report relapsing frequently with same sex friends, and women showed a tendency to relapse in the presence of romantic partners. Men also tend to report more positive mood states during relapse than women, which is congruent with the finding that women report more depression. Severity of drinking pattern was found to be an important confounding variable in these analyses. It is suggested that gender differences found in individuals in treatment for alcohol problems may reflect societal differences between men and women, and that taking these differences into account in designing treatment programs may improve outcomes.

When anxiety attacks: treating hyperventilation and panic

The athlete who panics or hyperventilates requires immediate stabilization and assessment to rule out more serious diagnoses. Repeated attacks may indicate panic disorder, which can be treated effectively with a combination of psychological and pharmacologic therapy. Drug options include selective serotonin reuptake inhibitors, benzodiazepines, tricyclic antidepressants, and monoamine oxidase inhibitors.

Evaluation and diagnosis of ankle injuries

The evaluation of ankle injuries is a common challenge for family physicians. Diagnosis is made by using knowledge of the anatomy and function of the ankle joint to aid in taking an adequate history and performing an appropriate physical examination. The patient should be questioned about the mechanism of injury, previous injury, disability, treatment and pain. The ankle should be evaluated for ecchymosis, swelling, areas of tenderness and laxity. These measures help to determine what, if any, additional diagnostic procedures may be needed. Most ankle sprains are lateral, affecting the anterior talofibular, calcaneofibular and posterior talofibular ligaments. Other injuries include medial ankle sprains affecting the deltoid ligament, trauma to the Achilles and peroneal tendons, tarsal tunnel syndrome, fractures, syndesmotic sprains, synovial impingement and chronic instability. Criteria for radiographic evaluation include inability to bear weight initially or when examined, and tenderness over the medial or lateral malleolus. Accurate diagnosis is critical for appropriate treatment and minimizing functional disability.

A psychoeducational group intervention for family members of persons with HIV/AIDS

We describe a psychoeducational group intervention for family members of persons living with AIDS. The 33 family members were compared with 13 waiting-list controls in order to evaluate the effectiveness of the intervention. We focus on the practice aspects of the intervention, its development and implementation, and our belief that it is an apparently effective approach for helping family members work through the social and emotional aspects of the devastating impact of HIV/AIDS.

Fluorescence induction curves registered from individual microalgae cenobiums in the process of population growth

Registration of chlorophyll fluorescence induction curves (IC) from individual microalgae cenobiums was performed during Scenedesmus quadricauda culture growth. Emphasis was placed on the analysis of patterns of the slow phase of IC, since these slow fluorescence transitions reflect complex interactions between primary and secondary photosynthetic processes. A classification was performed of the ICs obtained according to the patterns of their slow phase. Four different types of such patterns were distinguished. The microalgae population structure with respect to IC patterns was investigated at different stages of culture growth. The distribution of microalgae cenobiums over the patterns of IC was found to change in accordance with the stage of population development. At the stage of the population growth enhancement, nonmonotonous IC dominated with a high steady-state level of fluorescence. The stage of linear growth was characterized by IC with monotonous decay kinetics and low steady-state level of fluorescence. At the third stage including the phases of growth inhibition, stationary state and the beginning of cell death the population structure was the most heterogeneous, with all IC patterns observed.

The coincident diagnosis of pelvic inflammatory disease and pregnancy: are they compatible?

OBJECTIVES

To determine the frequency of coincident diagnoses of pregnancy and pelvic inflammatory disease (PID) in adolescents seeking care at a large urban children's hospital.

DESIGN

All inpatient medical records for the period from January 1, 1984 through December 31, 1993 were searched for dual diagnoses of pregnancy and PID (presumed secondary to endometritis, salpingitis, or both). During this period, there were 1205 patients admitted for PID, 67 of whom were also pregnant. Ten of these 67 admissions were eliminated from this study because of incomplete or missing records, errors in diagnosis, or lack of proper examinations. The charts of the remaining 57 subjects were reviewed for demographics, physical findings, and laboratory studies.

OUTCOME MEASURES

For the purposes of this study, a diagnosis of suspected PID was defined as lower abdominal tenderness, cervical motion tenderness, and adnexal tenderness ("major criteria"), as well as either a positive cervical specimen for Neisseria gonorrhoeae or Chlamydia trachomatis or adnexal fullness ("minor criteria").

RESULTS

The mean age of the 57 subjects was 16.8 years, and the mean gestational age was 6.7 weeks. Twenty-four (42.1%) of the subjects met the criteria for a concurrent diagnosis of PID and pregnancy; 13 had physical findings and a positive cervical specimen for either N. gonorrhoeae or C. trachomatis, and 11 subjects had the minor criteria of adnexal fullness. Twenty-six (45.6%) of the 57 subjects were primigravida, 35 (61.4%) had a history of a sexually transmitted disease, and 18 (31.6%) had been previously admitted to a hospital for PID.

CONCLUSION

This study found that PID and pregnancy can coexist in adolescents. Therefore, physicians who treat adolescents must consider the possibility of PID in pregnant adolescents presenting with abdominal pain.

Purtscher's retinopathy associated with mandibular fracture: a case report

This report describes irreversible deterioration of vision after Purtscher's retinopathy associated with a fractured mandible. This rare phenomenon will be discussed, its literature will be reviewed, and its possible etiology will be suggested.