Journal of the Association for Academic Minority Physicians : the official publication of the Association for Academic Minority Physicians最新文献

The abuse of women has reached epidemic proportions. There are an estimated 12 million abused women in the United States. Reported cases of abuse, however, range from 2 to 4 million. Less than 15% of these women ever seek medical care. Of women who do seek care, an estimated 75% use the emergency department, often presenting with complaints not readily suggestive of abuse. Reports indicate, however, that emergency departments consistently identify less than 10% of all abuse cases. In 1991 and 1992, the Joint Commission on Accreditation of Healthcare Organizations established standards for emergency departments to develop policies and procedures for the identification, treatment, and referral of female and elderly victims of abuse. Virtually all emergency medicine professional societies have official policies to encourage development of protocols for abuse identification and management. The American Medical Association and the Department of Health and Human Services have likewise developed guidelines to help emergency departments achieve these national health care objectives. Currently, less than 50% of all emergency departments have established algorithms to address abused women who present to the emergency department for treatment. This article reviews current health policy, examines the impediments to the detection of abuse in the emergency department, and recommends mechanisms to enhance the awareness of abuse among emergency department personnel.

Children with sickle cell disease have decreased height and weight when compared with their peers. Although exact reasons for poor growth have not been established, increased calorie and protein needs and deficiencies in zinc, folic acid, and vitamins A, C, and E may be factors. To determine whether inadequate nutrient intake contributes to this poor growth, we conducted a survey of the nutrition knowledge and practices of families affected by sickle cell disease. Sixty-one patients with a median age of 8 years (range, 13 months to 17 years) participated in the study. Patients with homozygous S hemoglobin (sickle cell) disease (Hb SS, n = 34) and sickle beta zero thalassemia (Hb S beta zero-thalassemia, n = 2) were combined; 19% were below the fifth percentile for height. The other patients, with sickle hemoglobin C disease (Hb SC, n = 21) and sickle beta plus thalassemia (Hb beta(+)-thalassemia, n = 4), were grouped, and 4% were below the fifth percentile for height (P = .043). Ninety percent of the study patients or their parents were familiar with the food groups indicated on the US Department of Agriculture's Food Guide Pyramid, but most patients failed to consume appropriate amounts from those groups. Although two thirds of the patients ate the recommended number of servings daily from the meat group, only 20% to 31% of the recommended servings from each of the other food groups was consumed. This was possibly related to low socioeconomic status. The patients in the Hb SS group ate significantly less from the bread (P < .037) and milk (P < .022) categories than the patients in the Hb SC group. Fifty-nine percent of families had incomes below the poverty level, and 79% participated in a food assistance program. We conclude that the nutrient intake of patients with sickle cell disease is often inadequate. Education for patients with sickle cell disease should focus on (1) specific nutrient needs, with proper distribution of dietary intake among the food groups, (2) ways to provide nutritious meals on a limited income, and (3) methods for increasing calorie and protein intake.

Our study's objective was to clarify the nosologic status of children who satisfy diagnostic criteria for bipolar disorder. Using blind raters and structured psychiatric interviews as well as data from other instruments, we undertook studies from various vantage points, examining children with bipolar disorder to confirm the existence of the diagnosis in children and to clarify its clinical course and characteristics. We found that (1) bipolar disorder in children referred to our clinical center is not as rare as previously thought; (2) bipolar disorder in children commonly presents with attention-deficit hyperactivity disorder, which makes diagnosis difficult; and (3) bipolar disorder in children presents with a clinical picture considered atypical by adult standards, with irritability, chronicity, and symptoms of mania mixed with those of depression. Our data suggest that childhood bipolar disorder is more common than previously thought, but it may be difficult to diagnose because of comorbidity with attention-deficit hyperactivity disorder and a developmentally different presentation from adults.

This study's purpose was to compare breast screening outcomes, health practices, and risk factors for low-income African-American and white women who participated in a multistrategy cancer control intervention. Subjects were recruited from their communities to participate in breast screening activities (clinical breast examination and mammography testing). Data were collected via a screening intake form for a 2-year period (mid- 1994 to mid- 1996). As a result of the recruitment. 1444 women enrolled for breast screening services. They included 282 African Americans. 1079 whites, and 83 other minorities. African-American and white women alike reported deficiencies in monthly breast self-examination practices and previous mammography use. However, more African-American women than white women reported monthly breast self-examination practice (P < 001). More white than African-American women reported having had a previous mammogram (P < .002). Examination of selected risk factors showed that both African-American women and white women had minimum family history. A comparison of breast screening outcomes showed that African-American women presented with slightly more abnormalities than did white women after undergoing clinical breast exams and mammography. However, no significant difference was found when comparing these variables. Overall, African-American women were as likely as white women to participate in screening activities. There was little difference between these groups when comparing screening outcomes, health practices, and risk factors.

This article addresses the clinical issues relevant to mental health workers when evaluating children of diverse cultures who live in conditions of persistent poverty. We suggest a model that considers the social as well as the biologic risk factors affecting these children and that includes the importance of culture on symptom expression and health-seeking behavior. The discussion includes specific assessment approaches sensitive to the context in which these children develop and the psychiatric diagnostic entities and treatment approaches thought to be particularly relevant to these children.

In the course of investigating severe, shooting leg pains in a patient with chronic inflammatory demyelinating polyradiculoneuropathy, we observed massive nerve root enlargement on magnetic resonance imaging. Clinical evaluation ruled out other possible etiologies. Lumbar laminectomy was performed in an attempt to alleviate the pain, with poor results. A review of the literature revealed that seven similar cases have been reported in the past. We report another case and a review of the literature.

We studied all 39 patients who were on maintenance hemodialysis for 10 years or more (range, 10 to 24 years) in three free-standing, not-for-profit hemodialysis units to determine the prevalence of malignancy. The three dialysis units have a total patient population of 470, all of whom are cared for by the same group of physicians. From the same dialysis units, we selected a control cohort of 37 patients matched for age, gender, race, and renal diagnosis who were on hemodialysis for 3 years or less (short-term patients). Control patients were selected by randomly choosing the next patient who filled the criteria for duration of dialysis from the roster of all patients at a facility. Clinically overt malignancy during dialytic therapy was determined by history, physical examination, Pap smear, mammogram, and colonoscopy in patients with gastrointestinal bleeding. The mean age (+/-SE) of the long-term patients was 51.8 +/- 1.9 years, and that of the control group was 51.5 +/- 2.4 years (P = .92). Thrice-weekly hemodialysis prescriptions were similar in both groups: long term, 3.5 +/- 0.02 hours; control, 3.4 +/- 0.02 hours (P = .27). No malignancy was detected in either the long-term or the short-term patients, and no patient of either group had a malignancy in the past. Colonic biopsy specimens of four long-term patients who had gastrointestinal bleeding were normal. The prevalence of malignancy was not increased in patients who were on maintenance hemodialysis for 10 years or longer.

Although the majority of patients with endometrial cancer have a good prognosis, subgroups of individuals are at risk of more aggressive disease. Early detection programs should target individuals who have the highest risk of advanced disease, high-risk histology, and poorly differentiated tumors. This will afford the greatest improvement in survival. Screening of the general population is not cost-effective and indeed may incur iatrogenic morbidity. Recent data also suggest that routine screening of patients receiving tamoxifen citrate may not be indicated. This area is still being investigated. While screening is not appropriate for the general population, a strategy of early evaluation of postmenopausal bleeding with judicious use of endometrial biopsy is important for the early detection of endometrial cancer. Ultrasound is most effective in excluding pathology in symptomatic patients whose biopsy specimen is nondiagnostic. Fractional dilation and curettage is reserved for patients with abnormal vaginal bleeding who cannot undergo office biopsy or who experience persistent symptoms.

Although medication-induced (pill) esophagitis has been recognized for a long time, little data are available on the risk of recently introduced slow-release medications. These formulations may have an obstructive capability (undissolved medication blocking an obstructed lumen) or may cause tissue irritation (continuous leakage from a slowly disintegrating pill). We observed a patient with esophageal carcinoma who developed complete obstruction when three Procardia XL (nifedipine) extended-release tablets blocked the narrowed lumen. An intact Procardia XL tablet and a washed shell as a control were implanted subcutaneously in a rat. The intact pill produced a large inflammatory mass: in contrast, no inflammatory response was noted at the control site implanted with a washed shell. In vitro testing of seven different slow-release medications revealed a wide difference in their solubility at a neutral pH and in gastric juice of pH 1.8 (simulation of esophageal or gastric environment). Theolair-SR (anhydrous theophylline, sustained-release) tablets had the highest obstructive, but no irritating potential. Cardizem SR (diltiazem hydrochloride) sustained-release capsules dissolved promptly without obstructive potential. Adalat CC (nifedipine) extended-release tablets also dissolved early at both pH values. Cardizem CD (diltiazem hydrochloride) extended-release capsules and Calan SR (verapamil hydrochloride) sustained-release oral caplets disintegrated into granules that had a low obstructive potential, but their prolonged presence increased the risk of tissue irritation. Ecotrin (enteric-coated aspirin) tablets had a high obstructive and no irritating potential in the first 24 hours, after which they disintegrated and directly contacted the tissue. Procardia XL extended-release tablets had an insoluble shell that continued to leak a tissue-irritating content even after 48 hours, generating a prolonged obstructive and irritating condition. In conclusion, slow-release medications greatly increase the risk of esophageal injury. Their obstructive and tissue-irritating potentials differ widely. Slow-release formulations should be contraindicated in patients who have obstructive esophageal and gastric disorders.