Band 93, Heft 3

The following annotated bibliography has been developed for the purpose of providing to primary care physicians a handy source of review articles and major studies in the field of nephrology, hypertension, and fluid and electrolyte disorders. Almost all of the articles are review articles of clinical topics that would be of interest to the practicing physician. JAOA will be publishing additional annotated bibliographies in various fields of internal medicine over the next several months. This is the second in the series. Part 1 appeared in the January 1993 issue (93:50-65). Others will appear in forthcoming issues of THE JOURNAL.

Eleven diurnally active asthma patients having a history of nocturnal asthma and treated regularly with albuterol or metaproterenol alone or with twice-daily sustained-release theophylline were evaluated for day-night pattern in peak expiratory flow (PEF) and use of supplemental j3-agonist aerosol for relief of acute asthma. Overall, significant daynight variation was observed in the supplemental use of j3-agonist medication and in airway patency. The patients managed by albuterol or metaproterenol alone used supplemental j3-agonist medication significantly more between 4 AM and 8 AM and also 8 PM and midnight in comparison to 4 PM to 8 PM; this was not true for those treated with both theophylline and j3-agonist aerosol. In patients taking a j3-agonist bronchodilator, the 24-hour mean PEF was greater than in those who also took theophylline, but the day-night variation in PEF was comparable. Supplemental isoproterenol use was significantly correlated with circadian amplitude of the PEF rhythm, but not with the 24-hour mean PEF. The greater the day-night variation in PEF, the greater the reliance on a supplemental j3-agonist bronchodilator.

Thoracic outlet syndrome involves more than just local neurovascular compression. Myofascial release treatments and stretching exercises may be only partially or temporarily successful unless all related components of somatic dysfunction, including craniosacral mechanisms, are addressed. Structural and postural abnormalities in the frontal plane, as with a short leg, and in the sagittal plane, such as lumbopelvic imbalances, as well as neural involvement all contribute to thoracic outlet syndrome symptoms. Once segmental restrictions are treated and symptoms diminish, postural correction and strengthening exercises may be initiated. Osteopathic diagnosis and treatment of the local, regional, and remote structural problems is necessary for optimal treatment of thoracic outlet syndrome and the maintenance of a symptom-free status.

Clinical medicine is a pragmatic discipline. Because of its aim to alleviate pain and suffering as well as to foster well-being, its practitioners can be lulled into thinking that there are times when basic science is irrelevant to the practice of medicine. This attitude is evaluated by comparing a 19th century medical curiosity, the nasogenital reflex, to a set of reflexes, the little used and little known Chapman's reflexes. We must always attempt to substantiate the principles of clinical medicine.

In. education, "assessment" refers to the ongoing, systematic process of identification of goals, development of methods for measuring progress toward attaining those goals, and use of resulting information to make revisions in educational programs. Recently, state-review programs and accrediting agencies have focused review efforts on outcomes of the educational process. The West Virginia School of Osteopathic Medicine has developed a successful outcomes assessment program that includes information regarding graduates' activities. The school is now considering new programs regarding more comprehensive assessment of clinical outcomes.

Rarely, interns or residents may be unable or unwilling to perform satisfactorily in a graduate medical education program. In such instances, the director of medical education or residency director (or both) must inform the trainee of his or her deficiency and provide appropriate counseling, generally with the opportunity for remediation. If dismissal becomes necessary, due process must be followed, and the institution must keep documentation that appropriate procedures were followed These necessary procedures are outlined herein.

The lupus anticoagulant has been understood for more than 40 years. However, reports of obstetric cases, although available, are not frequent. The author reviews the literature on this subject, including current recommendations on managing the problem in pregnancy. He reports a single case that involved a spontaneous abortion and a subsequent pregnancy in the same person. The second pregnancy during which the patient received prednisone and aspirin therapy, had a successful outcome.

Neurogenic pulmonary edema is a potential complication of severe central nervous system insult. In the patient described, neurogenic pulmonary edema resulted from gunshot injuries to the head. Aggressive supportive care and intravenous administration of dopamine successfully resolved this pulmonary complication. Although such treatment is crucial in patients with possibly reversible central nervous system injury, the patient described had irreversible brain injury. The authors discuss current theories of the pathogenesis as well as diagnosis and treatment options.