Cryosurgery in cutaneous leishmaniasis

Thirty patients with cutaneous leishmaniasis were treated with cryotherapy using a CO2 cryomachine and all were cured without noticeable scarring within 4-5 weeks, with no relapse. Histopathological examination showed that cryotherapy eradicated all parasites in less than 1 hour. Leishmania tropica, L. ethiopica and L. brasiliensis are all markedly thermosensitive and thus cryotherapy seems parasiticidal to all types. Adequate cryotreatment of cutaneous leishmaniasis will preclude the development of mucocutaneous extension, and its use in mucocutaneous disease is also recommended.

Ethnic differences in the prevalence of endoscopic esophagitis and Barrett's esophagus: the long and short of it all

Recent studies indicate that the prevalence of gastroesophageal reflux disease in Asia is either increasing or better recognized. There is a paucity of reliable data on the prevalence of reflux disease in the various races in general and in Malaysia, in particular. The prevalence of erosive esophagitis and Barrett's esophagus in a multiethnic Malaysian population was studied, as well as the relationship of various factors associated with reflux disease. Chinese, Malay, and Indian patients undergoing gastroscopy in a tertiary referral center were assessed for the presence of esophagitis, hiatus hernia, and Barrett's esophagus. Patient demographics and risk factors associated with gastroesophageal reflux disease were also documented. The prevalence of endoscopically documented esophagitis among 1985 patients was 6.1%, the majority of which were mild, Grade I or II (88%). There was a preponderance of Indians with esophagitis, as well as males (P < 0.05) and those with the presence of a hiatus hernia (P < 0.01). Long-segment Barrett's esophagus was found in 1.6% of patients, and short-segment Barrett's in 4.6%. Indians had the highest prevalence of Barrett's esophagus compared with Chinese (P < 0.05) or Malays (P < 0.01). Hiatus hernia and erosive esophagitis were both positively associated with Barrett's metaplasia (P < 0.01). A significant proportion of Malaysian patients undergoing endoscopy has mild reflux esophagitis and Barrett's esophagus. Indian ethnicity and the presence of a hiatus hernia were significantly associated with endoscopic esophagitis and Barrett's metaplasia. These observed racial differences warrant further study.

Cardiopulmonary resuscitation in elderly patients hospitalized in the 1990s: a favorable outcome

OBJECTIVE

To compare the clinical characteristics and survival of elderly and younger hospitalized patients who sustain cardiac arrest and receive cardiopulmonary resuscitation (CPR) in the 1990's and to assess predictors of survival.

DESIGN

Retrospective survey of cardiac arrest database and hospital charts, plus telephone follow-up.

SETTING

450-bed acute care teaching hospital.

STUDY POPULATION

Seventy-eight hospitalized patients 70 years or older and 73 hospitalized patients under 70 years of age.

MEASUREMENTS

Survey of cardiac arrest data base, hospital charts, and telephonic follow-up to allow (1) comparison of clinical characteristics, survival, and long-term follow-up between two age groups and (2) univariate and multivariate analysis of predictors of mortality.

MAIN RESULTS

Pre-arrest clinical characteristics were not significantly different between the age groups. Prior to arrest the majority of patients were functionally active, and over one-third were hospitalized for acute coronary artery syndromes. In approximately 85% of the patients, the arrest was witnessed, and 70% of the patients had their cardiac rhythm monitored at onset of the arrest. Survival was not significantly different between the age groups; 26% of the total 151 patients were discharged. No significant difference was noted in pre-post arrest functional status of survivors. Survival at 1, 2, and 3 years in elderly and younger survivors was 86% versus 80%, 76% versus 67%, and 71% versus 61%, respectively. Multivariate analysis identified the presence of coronary artery disease, admission systolic blood pressure, and functional level to be independent pre-arrest predictors of mortality. At the time of the arrest, the initial cardiac rhythm and duration of CPR were found to be independent predictors of mortality.

CONCLUSIONS

Elderly patients hospitalized in the 1990's who receive CPR have outcomes similar to younger patients who receive CPR. The favorable outcome in the elderly patients may reflect patient selection: the majority of our patients were functionally active prior to hospitalization, without multiple serious illnesses; many were hospitalized for acute coronary artery syndromes; and, in most cases, the arrest was witnessed with the patient's cardiac rhythm monitored at onset of the arrest.

Septic pulmonary embolism due to periodontal disease

Three weeks following a toothache, a 56-year-old man developed cough, sputum, fever, and pleuritic chest pain. He had mild periodontal disease and his chest radiographs and chest computed tomographic (CT) scans showed multiple pulmonary nodules. The CT scan strongly suggested septic pulmonary embolism. Aspirated pus from one of the nodules yielded pure growth of Streptococcus intermedius. Lesions resolved with antimicrobial therapy. The usual predisposing factors for septic pulmonary embolism were absent, and, the isolation of S intermedius from the pus, the antecedent toothache, and periodontal disease all suggested the gingiva as the source. We hypothesize that periodontal infection led to bacteremia, seeding of the lungs, and multiple anaerobic pulmonary abscesses, akin to reported instances of infective endocarditis from dental foci without any prior dental procedures. To our knowledge, this presentation of septic pulmonary embolism is unprecedented.

Endotracheal intubation by paramedics during in-hospital CPR

STUDY OBJECTIVE

To examine whether well-trained paramedics can perform emergent, successful, uncomplicated, endotracheal intubations during in-hospital cardiopulmonary resuscitation (CPR).

DESIGN

Retrospective review of medical records of in-patients undergoing emergent, endotracheal intubations during in-hospital, CPR over 8 months, with comparison of the performance of the paramedics against that of other hospital-based personnel.

SETTING

A 437-bed Midwestern community teaching hospital.

PATIENTS

Adult in-patients in general medical/surgical wards.

MAIN OUTCOME MEASURES

The rapidity of response of paramedics and other medical personnel to a cardiorespiratory arrest (code 4) announcement, and reported difficulties, success rate, rapidity, and complications of endotracheal intubation.

RESULTS

In the 47 cardiorespiratory arrests requiring intubation that we analyzed, the median response times (with values in parentheses representing interquartile range [IQR]) for paramedics, nurse anesthetists (CRNAs), anesthesiologists, and other physicians respectively, were 2.00 (4.25), 4.00 (2.0), 4.00 (15.0), and 7.00 (8.0) min, requiring a median of 1.0 attempt for all groups (mean values, 1.4, 1.125, 1.0, and 1.4 respectively) to place an endotracheal tube. The paramedics were successful in 13 of 15 instances. Median times (seconds) required for intubation by various groups (same order as response times, with IQR given in parentheses) were 60 (30), 150 (270), 45 (30), and 60 (30). Difficulties were reported by all groups, including patients' resistance to intubation, airway obstruction by extraneous material, and difficulty in visualizing the glottis. Reported complications (4%) were confined to groups other than the paramedics.

CONCLUSIONS

Paramedics can successfully, and without undue difficulty or complications, place endotracheal tubes during in-hospital CPR. Appropriately trained paramedics may be incorporated into hospital-based CPR teams in two contexts: (1) to provide an acceptable, long-term solution to the scarcity of personnel highly skilled in endotracheal tube placement during in-hospital CPR, and (2) to fulfill the need for hospitals to have on-site, qualified professionals to perform emergent endotracheal intubation during CPR. In the latter situation, personnel skilled in airway management could supplement the paramedics on demand. Further investigation in this area could be fruitful in view of the small sample size covered in this study.

Metastatic renal cell carcinoma simulating sarcoidosis. Analysis of 12 patients with bilateral hilar lymphadenopathy

Case summaries of four patients with bilateral hilar lymphadenopathy (BHL) caused by metastatic renal cell carcinoma are presented, and these and eight similar cases from the literature are analyzed. In nine patients, sarcoidosis was the provisional clinical diagnosis, but four of these patients had a past history of renal cell carcinoma. In the remaining five patients, a distinction from sarcoidosis could not be made by history, physical examination, and chest roentgenogram. This underscores the need for tissue confirmation in the diagnosis of sarcoidosis and alerts the physician to consider metastatic renal cell carcinoma in the differential diagnosis of BHL.

Flat colonic adenomas in Malaysia: fact or fancy?

BACKGROUND

Some two-thirds of colorectal carcinomas arise from adenomatous polyps, and as such, screening by colonoscopy and polyp removal should significantly reduce colorectal cancer. This has not been the case, as evidenced by recent studies, which revealed that endoscopy failed to prevent up to 50% of all subsequent carcinomas. Flat or depressed adenomas, frequently reported from Japan but rarely elsewhere, might explain the 'missed carcinomas.' Detection of flat adenomas has not been previously reported from Malaysia.

METHODS

In the present prospective study, 426 consecutive patients underwent colonoscopic examination between March 1997 and January 2000, for a variety of bowel symptoms. The examinations were performed by an experienced endoscopist using a standard colonoscope and methylene blue dye spraying technique. Macroscopically, flat adenomas were defined using the criteria proposed by Sawada.

RESULTS

Twenty-nine adenomas were identified in 12 patients, of which 15 were polypoid and 14 were flat, with no depressed lesions. Eight polypoidal lesions and all the flat adenomas contained mild or moderate areas of epithelial dysplasia. Seven severely dysplastic polyps were identified. One Duke's A polypoidal cancer and two advanced carcinomas were also found. All the severely dysplastic lesions and Duke's A carcinomas were found in polyps greater than 10 mm in mean size. The flat adenomas were all less than 5 mm in size.

CONCLUSIONS

A significant proportion of colonic adenomas in Malaysian patients appear as small flat lesions, which could easily be missed during endoscopy. Increased recognition and treatment of flat adenomas among colonoscopists is warranted.

Pulmonary embolism. How to 'nail down' the diagnosis

Pulmonary embolism is a common problem in hospitalized patients. Because its initial symptoms may be nonspecific, pulmonary embolism may be difficult to diagnose. A high index of suspicion, together with careful selection of diagnostic tests, is essential. An algorithm for clinical assessment of suspected pulmonary embolism is presented here.

Chronic obstructive pulmonary disease. Reversing airflow obstruction from chronic bronchitis and emphysema

Chronic obstructive pulmonary disease (COPD) describes a group of disorders that cause obstruction to expiratory airflow. COPD should be suspected in a patient who has cough, sputum production, wheezing, and/or inappropriate dyspnea on exertion in the setting of prolonged exposure to cigarette smoke. With smoking cessation, avoidance of occupational and other bronchial irritants, and use of bronchodilators, antibiotics, and long-term oxygen when appropriate, the patient can minimize limitations on activity and complications.

Peritoneal trophoblastic implant

A case of persistent trophoblastic tissue on the pelvic peritoneum is presented. While most cases are secondary to conservative surgery for tubal ectopic pregnancy, primary implantation can also occur as highlighted by this case. A brief pathophysiology of the condition is presented. The importance of monitoring the serum for beta subunit human chorionic gonadotrophin (HCG) is emphasised.

Incidence and distribution of intrathoracic metastases from renal cell carcinoma

Chest roentgenographic findings in 46 patients with renal cell carcinoma were analyzed and correlated to clinical and pathologic findings. Twenty-five patients (54.3%) had intrathoracic metastasis, 17 (37%) of whom had roentgenographic evidence of intrathoracic metastasis at the time of initial diagnosis. Lung metastasis was present in 14 patients (30%), alone in ten patients and along with mediastinal or pleural metastasis in four patients. Mediastinal lymph node metastasis was present in 13 patients (28.2%) and was distributed in the following locations: bilateral hila, six; right hilum, two; right paratracheal area, two; left hilum, one; left paratracheal area, one; and left hilum and right paratracheal area, one. Mediastinal lymph node enlargement was the sole roentgenographic finding in six patients (13%). Metastasis to the lungs or mediastinum may already be present in more than a third of the patients with renal cell carcinoma at the time of diagnosis. Mediastinal lymph node metastasis from renal cell carcinoma occurs more frequently than previously reported and may be the only chest roentgenographic manifestation of the disease.

Iliofemoral thrombosis in a case of chicken pox

A case of iliofemoral thrombosis possibly related to chicken pox infection is reported. Treated with rest and anti-coagulants, the patient made a satisfactory recovery.