Volume 95, Issue 1

During the past 2 years, an increasing number of gynecologic surgeons have performed laparoscopy-assisted vaginal hysterectomy (LAVH) and laparoscopic hysterectomy (LH). Although these procedures have become more common, they are still considered controversial. Many gynecologists question their cost, safety, efficacy, and indications. We reviewed and analyzed the perioperative and postoperative course of ten patients as well as the total cost. The patients who underwent these procedures were compared with ten matched patients who underwent abdominal hysterectomy for similar indications. Compared with control subjects, patients in the laparoscopic group had a shorter hospitalization stay (2.2 days vs 4.2 days), shorter recovery (2 weeks vs 5 weeks), and 28% fewer complications. Although the LAVH took significantly longer than TAH (3.28 hours vs 1.75 hours), the total hospital costs and charges for both procedures were similar. As technology advances and techniques are modified, the laparoscopic approach should reduce hospital costs and charges significantly. The current results suggest that LAVH may eventually be preferred to the TAH approach by physicians and their patients.

Surveillance of drug consumption and disease incidence from medical relief missions in two locations (southeast Asia and eastern Africa) revealed close similarities. Analgesics, antibiotics, antimalarials, antihistamine or decongestant preparations (or both), bronchodilators, and scabicides were the 10 most commonly used drugs. Orthopedic, respiratory, gastrointestinal, dermatologic, and ophthalmic conditions, malaria, sexually transmitted diseases, and parasitic infestations were encountered most frequently. Recognition and early treatment of xerophthalmia, trachoma, and onchocerciasis, which are rare in more developed countries but common at tropical latitudes, can prevent the blindness that results from untreated disease progression. Pulsetemperature relationships and fever patterns may offer diagnostic clues to physicians deprived of laboratory support. Important logistic considerations, disease incidences, and selected topics and idiosyncrasies of humanitarian aid missions to tropical communities are discussed in hopes of aiding providers who are planning future relief missions.

Unstable angina is one of the most common reasons for hospital admission in the United States and causes substantial morbidity and mortality. Diagnosis of unstable angina is complicated by the dynamic range of presentations, which can vary between atypical chest pain and acute myocardial infarction. Overcautious management can result in unnecessary hospital admission, whereas inappropriate conservative strategies can cause cardiac injury and death. To define treatment strategies for these patients, the US Agency for Health Care Policy and Research in March 1994 published guidelines on the diagnosis and management of unstable angina. The emphasis is on diagnosis or exclusion of coronary artery disease, establishment of the patient's risk for adverse outcome, and triage to the most appropriate treatment regimen. The guidelines emphasize the use of aspirin, heparin sodium, nitroglycerin, and [3-blockers as the core therapy. Appropriate strategies are reviewed, starting with intensive medical management and ending with patient care after discharge. Many physicians will probably modify their approach to the diagnosis and treatment of unstable angina on the basis of these new guidelines.

The metabolic acidosis resulting from poor tissue perfusion is considered to have several significant hemodynamic effects. Correction of the acidosis with sodium bicarbonate seems to be a rational approach to this problem. However, the current medical literature shows little clinical benefit to this tactic. In fact, indiscriminate bicarbonate administration may, itself, have deleterious effects. Concurring with the absence of a consistent therapeutic advantage to the use of sodium bicarbonate in the treatment of lactic acidosis due to inadequate tissue perfusion, the American Heart Association removed the routine use of sodium bicarbonate from the treatment of cardiac arrest in the algorithms of the Advanced Cardiac Life Support course. Although the debate continues, a detailed review of the medical literature does not support the use of sodium bicarbonate in this setting.

Back pain, a common complaint familiar to all physicians, can be either a manifestation of musculoskeletal dysfunction or a symptom of a more serious underlying disease. Unfortunately, the diagnosis can be difficult, and back pain that is not resolved by conservative treatment requires aggressive investigation. The author presents the case history of a 17-year-old patient whose back pain had been extensively evaluated by a series of specialists to no avail until further workup revealed the problem to be Ewing's sarcoma. The steps required to diagnose elusive back pain are presented, together with a brief discussion of cauda equina syndrome and conus medullaris syndrome, components of both of which were found in this patient.