doi: 10.1001/archinte.1985.00360120015001pmid: N/A
This article is only available in the PDF format. Download the PDF to view the article, as well as its associated figures and tables.
doi: 10.1001/archinte.1985.00360120025002pmid: N/A
This article is only available in the PDF format. Download the PDF to view the article, as well as its associated figures and tables.
Sider, Roger C.;Clements, Colleen D.
doi: 10.1001/archinte.1985.00360120037003pmid: N/A
Abstract The belief that patient choice constitutes the basis and primary good for medical ethics is rapidly gaining support among influential physicians. The American Board of Internal Medicine's proposed Principles Regarding Humanistic Qualities of Residents asserts, "The resident must care for patients in terms of the patients' values which often differ from the residents' personal values."1 The ten signatores to a recent article on the care of the terminally ill begin by declaring the centrality of the patient's right to make decisions about his or her medical treatment.2 A series of President's Commission Reports have now enshrined this perspective in federal guidelines.3-5 Such a conception of medical ethics, which we have critiqued elsewhere,6-9 is remarkable for its profound divergence from historic medical and human values, its cultural relativism,10 and its rapid assimilation into American medicine. Because of its congruence with the social mores of the last References 1. Principles of ethical requirements of residents. Ann Intern Med 1983;99:720-724.Crossref 2. Wanzer SH, Adelstein SJ, Cranford RE, et al: The physician's responsibility toward hopelessly ill patients. N Engl J Med 1984; 310:955-959.Crossref 3. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research: Screening and counseling for genetic conditions . Washington, DC, President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, 1983. 4. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research: Deciding to forego life-sustaining treatment . Washington, DC, President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, 1983. 5. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research: Making health care decisions . Washington, DC, President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, 1982, vol 1. 6. Clements CD, Sider RC: Medical ethic's assault upon medical values. JAMA 1983;250:2011-2015.Crossref 7. Clements CD: Bioethical essentialism and scientific population thinking. Perspect Biol Med 1985;28:188-207. 8. Sider RC: The ethics of therapeutic modality choice. Am J Psychiatry 1984;141:390-394. 9. Clements CD: Medical Genetics Casebook: A Clinical Introduction to Medical Ethics Systems Theory . Clifton, NJ, Humana Press, 1982. 10. Fox RC, Swazey JP: Medical morality is not bioethics: Medical ethics in China and the United States. Perspect Biol Med 1984;27:336-360. 11. Sider RC, Clements CD: Patient's ethical obligation for their health. Br J Med Ethics 1984;10:138-142.Crossref 12. Sider RC: Mental health norms and ethical practice. Psychiatr Ann 1983;13:302-309.Crossref 13. Kass L: Ethical dilemmas in the care of the ill: I. What is the physician's service? JAMA 1980;244:1811-1816.Crossref 14. Fletcher J: Situation Ethics: The New Morality . Philadelphia, Westminster, 1966. 15. MacIntyre A: After Virtue . South Bend, Ind, Notre Dame University Press, 1981.
Essin, Daniel J.;Steen, Stephen N.
doi: 10.1001/archinte.1985.00360120039004pmid: N/A
This article is only available in the PDF format. Download the PDF to view the article, as well as its associated figures and tables. Abstract Technology abounds in medicine today as it has in the past. It may be said that medicine is mankind's most concerted attempt to make beneficial use of the technology of the day. Although examples can be cited that extend back into the archaeological record, some of the most dramatic examples have occurred within the last century. One of the earliest applications of ionizing radiation was in medical imaging. Physicians made use of telephone exchanges long before the telephone was in widespread general use. The automobile was readily adopted as a faster means of making emergency visits than the horse and buggy. Additional dramatic examples are to be found in pharmaceutical chemistry, laser surgery, computed tomography, and nuclear magnetic resonance scanning, to name but a few. There is one area of medical practice that has been virtually untouched by technology and remains much as it did a century ago. That area
doi: 10.1001/archinte.1985.00360120041005pmid: N/A
Abstract Even experienced clinicians in endemic areas occasionally have difficulty diagnosing Rocky Mountain spotted fever (RMSF) in the early stages. Numerous pitfalls in diagnosis may test the acumen of even the best physicians. Rickettsia rickettsii, the cause of RMSF, has the potential to kill healthy persons of any age. Thus, physicians must be alert to the diagnosis and able to recognize usual and unusual clinical presentations. This is easier said than done. Patients with RMSF may not give a history of tick bite in up to a third of cases. To make matters worse, rash occasionally may not occur in the first three to six days of illness. In other cases, rash may first appear in the terminal stages of illness or, rarely, not at all.1 Tongue in cheek, Westerman2 coined the term Rocky Mountain spotless fever to describe these patients and emphasized that waiting for a rash to References 1. Sexton DJ, Bank PM, Weig S, et al: Late appearance of skin rash and abnormal serum enzymes in Rocky Mountain spotted fever: A case report. J Pediatr 1975;87:580-582.Crossref 2. Westerman RL: Rocky Mountain spotless fever: A dilemma for the clinician. Arch Intern Med 1982;142:1106-1107.Crossref 3. Walker DH, Lesesne HR, Varma VA, et al: Rocky Mountain spotted fever mimicking acute cholecystitis. Arch Intern Med 1985;145:2194-2196.Crossref 4. Jiménez J, Byrne WJ, Seibert JJ, et al: Gastrointestinal symptoms in Rocky Mountain spotted fever: Histopathologic findings of ulcerative enteritis with vasculitis. Clin Pediatr 1982;10: 581-584.Crossref 5. Davis AE Jr, Bradford AD: Abdominal pain resembling acute appendicitis in Rocky Mountain spotted fever. JAMA 1982;247: 2811-2812.Crossref 6. Middleton DB: Rocky Mountain spotted fever: Gastrointestinal and laboratory manifestations. South Med J 1978;71: 629-632.Crossref 7. Becker FE: Investigations on Rocky Mountain spotted fever in Colorado. J Infect Dis 1926;39:81-89.Crossref 8. Sexton DJ, MacCormack JN: Rocky Mountain spotted fever: Diagnosis. JAMA 1976;236:117.Crossref 9. Helmick CG, Bernard KW, D'Angelo LJ: Rocky Mountain spotted fever: Clinical, laboratory and epidemiological features of 262 cases. J Infect Dis 1984;150:480-488.Crossref
doi: 10.1001/archinte.1985.00360120042006pmid: N/A
Abstract The medical records of 27 patients with blood cultures positive for Acinetobacter calcoaceticus over a recent fiveyear period (0.7% of all positive blood cultures) were reviewed retrospectively to determine the epidemiologic and clinical significance of these isolates. Eighteen isolates represented true bacteremias, 16 of which were hospital acquired. Patients most frequently were located in an intensive care unit or on a surgical ward. A seasonal July-to-September peak incidence was noted. The most common site of primary infection was the respiratory tract. Aminoglycosides, alone or in combination with a second agent, were used to treat all but one infection. Bacteriologic cure was achieved in 15 cases (88%); six patients had polymicrobial sepsis that carried a higher mortality than pure A calcoaceticus bacteremia (50% vs 0%). Acinetobacter, a low-virulence opportunistic pathogen, may be an infrequent but potentially serious endemic agent of nosocomial bacteremia in some institutions. The prognosis of bacteremia, when appropriately treated, appears to be good. (Arch Intern Med 1985;145:2174-2179) References 1. Bauman P: Isolation of Acinetobacter from soil and water. J Bacteriol 1968;96:39-42. 2. Rosenthal SL: Sources of Pseudomonas and Acinetobacter species found in human culture material. Am J Clin Pathol 1974;62:807-811. 3. Al-Khoja MS, Darrell JH: The skin as a source of Acinetobacter and Moraxella species occurring in blood cultures. J Clin Pathol 1979;32: 497-499.Crossref 4. Gardner P, Griffin WB, Swartz MN, et al: Non-fermentative gramnegative bacilli of nosocomial interest. Am J Med 1970;48:735-740.Crossref 5. Glew RH, Moellering RC Jr, Kunz L: Infections with Acinetobacter calcoaceticus (Herellea vaginicola): Clinical and laboratory studies. Medicine 1977;56:79-97.Crossref 6. Daly AK, Postic B, Kass EH: Infections due to organisms of the genus Herellea. Arch Intern Med 1962;110:580-591.Crossref 7. Reynolds RC, Cluff LE: Infection of man with Mimeae. Ann Intern Med 1963;58:759-767.Crossref 8. Retailliau HF, Hightower AW, Dixon RE, et al: Acinetobacter calcoaceticus: A nosocomial pathogen with an unusual seasonal pattern. J Infect Dis 1979;139:371-375.Crossref 9. Lowes JA, Smith J, Tabagchali S, et al: Outbreak of infection in a urologic ward. Br Med J 1980;280:722. 10. Reyes MP, Ganguly S, Fowler M, et al: Pyrogenic reactions after inadvertent infusion of endotoxin during cardiac catheterizations. Ann Intern Med 1980;93:32-35.Crossref 11. Cunna BA, Klimek JJ, Gracewski J, et al: A common source outbreak of Acinetobacter pulmonary infections traced to Wright respirometers. Postgrad Med J 1980;56:160-172. 12. Buxton AE, Anderson RL, Werdegar D, et al: Nosocomial respiratory tract infection and colonization with Acinetobacter calcoaceticus. Am J Med 1978;65:507-512.Crossref 13. Abrutyn E, Goodhart GL, Roos K, et al: Acinetobacter calcoaceticus outbreak associated with peritoneal dialysis. Am J Epidemiol 1978;107: 328-335. 14. Smith RW, Masanari M: Room humidifiers as the source of Acinetobacter infection. JAMA 1977;237:795-797.Crossref 15. Norfleet RG, Mitchell PD, Mulholland DD, et al: Does bacteremia follow upper gastrointestinal endoscopy? Am J Gastroenterol 1981;76: 420-422. 16. Harvey K, Shuck S: Acinetobacter septicemia following prolonged intravenous therapy. Med J Aust 1977;2:121-124. 17. Castle M, Tenney JH, Weinstein MP, et al: Outbreak of multiplyresistant Acinetobacter in a surgical intensive care unit: Epidemiology and control. Heart Lung 1978;7:641-644. 18. Snydman DR, Malloy MF, Brock SM, et al: Pseudobacteremia: Falsepositive blood cultures from mist tent contamination. Am J Epidemiol 1977;106:154-159. 19. Acinetobacter calcoaceticus infections—United States, 1978. MMWR 1979;28:177-179. 20. Ramphal R, Kluge RM: Acinetobacter calcoaceticus variety anitratus: An increasing problem. Am J Med Sci 1979;227:57-66.Crossref 21. Raz R, Alroy G, Sobel JD: Nosocomial bacteremia due to Acinetobacter calcoaceticus. Infection 1982;10:168-171.Crossref 22. The nonfermentative gram-negative bacilli , in Koneman EW (ed): Color Atlas and Textbook of Diagnostic Microbiology . Philadelphia, JB Lippincott Co, 1983, pp 125-185. 23. Larson E: A decade of nosocomial Acinetobacter. Am J Infect Control 1984;12:14-17.Crossref 24. Acinetobacter calcoaceticus: Common nosocomial organism, uncommon pathogen , in National Nosocomial Infection Study Report: Annual Summary 1976 . Atlanta, Centers for Disease Control, 1978, pp 1-13. 25. Shawker TH, Kluge RM, Ayella RJ: Bacteremia associated with angiography. JAMA 1974;229:1090-1092.Crossref 26. Matsen JM: The source of hospital infection. Medicine 1973;52: 271-277.Crossref 27. Weinstein MP, Reller LB, Murphy JR, et al: The clinical significance of positive blood cultures: A contemporary analysis of 500 episodes of bacteremia and fungemia in adults: I. Laboratory and epidemiologic observations. Rev Infect Dis 1983;5:35-54.Crossref 28. O'Connell CJ, Hamilton R: Gram-negative rod infection: II. Acinetobacter infections in a general hospital. NY State J Med 1981;81:750-753. 29. Retailliau HF, Allen JR, Dixon RE, et al: Seasonal incidence of Acinetobacter infection. J Infect Dis 1979;140:275-276.Crossref 30. Larson EL: Persistent carriage of gram-negative bacteria on hands. Am J Infect Control 1981;9:112-119.Crossref 31. French GL, Casewell MW: Controlling the spread of Acinetobacter infection. Br Med J 1980;281:388.Crossref 32. Daschner F, Nopper S: Susceptibility of nosocomial Acinetobacter anitratus strains to 14 antibiotics. J Antimicrob Chemother 1980;6:415-416.Crossref 33. Crues JV III, Murray BE, Moellering RC Jr: In vitro activity of three tetracycline antibiotics against Acinetobacter calcoaceticus subsp anitratus. Antimicrob Agents Chemother 1979;15:690-693.Crossref 34. Maderazo EG, Quintiliani R, Tilton RC, et al: Activity of minocycline against Acinetobacter calcoaceticus var anitratus (Syn Herellea vaginicola) and Serratia marcescens. Antimicrob Agents Chemother 1975;8: 54-56.Crossref 35. MacLowry JD, Robertson EH, Friendman RB, et al: Antimicrobial susceptibilities of commonly encountered aerobic and facultative anaerobic bacteria , in von Graevenitz A (ed): Clinical Microbiology . Cleveland, CRC Press, 1977, vol 2, pp 566-598. 36. Murray BE, Moellering RC Jr: Aminoglycoside-modifying enzymes among clinical isolates of Acinetobacter calcoaceticus subsp anitratus (Herellea vaginicola): Explanation for high-level aminoglycoside resistance. Antimicrob Agents Chemother 1979;15:1190-1199. 37. Glew RH, Moellering RC Jr, Buettner VR: In vitro synergism between carbenicillin and aminoglycosides against Acinetobacter calcoaceticus , in Program and Abstracts, 16th Interscience Conference on Antimicrobial Agents and Chemotherapy . Chicago, American Society for Microbiology, 1976. 38. Jones RN, Fuchs PC, Gavan TL, et al: Cefuroxime, a new parenteral cephalosporin: Collaborative in vitro susceptibility comparison with cephalothin against 5,887 clinical bacterial isolates. Antimicrob Agents Chemother 1977;12:47-50.Crossref 39. Guerisse P: Cefuroxime for Acinetobacter infection. Lancet 1981;2:96.Crossref 40. Lang SDR, Edwards DJ, Durack DT: Comparison of cefoperazone, cefotaxime, and moxalactam (LY127935) against aerobic gram-negative bacilli. Antimicrob Agents Chemother 1980;17:488-493.Crossref 41. Applebaum PC, Tamin J, Stairtz J, et al: Sensitivity of Acinetobacter calcoaceticus strains to seven cephalosporins. Lancet 1981;2:472.Crossref 42. Neu HC: The new β-lactamase stable cephalosporins. Ann Intern Med 1982;97:408-419.Crossref 43. Neu HC: Structure-activity relations of new β-lactam compounds and in vitro activity against common bacteria. Rev Infect Dis 1983;5( (suppl) ):S319-S336.Crossref 44. Kesado T, Hashizume T, Asahi Y: Antibacterial activities of a new stabilized thienamycin, N-formimidoyl thienamycin, in comparison with other antibiotics. Antimicrob Agents Chemother 1980;17:912-917.Crossref 45. Bryan CS, Reynolds KL, Brenner ER: Analysis of 1,186 episodes of gram-negative bacteremia in non-university hospitals: The effects of antimicrobial therapy. Rev Infect Dis 1983;5:629-638.Crossref 46. Hermans PE, Washington JA: Polymicrobial bacteremia. Ann Intern Med 1970;73:387-392.Crossref 47. Roselle GA, Watanakunakorn C: Polymicrobial bacteremia. JAMA 1979;242:2411-2413.Crossref 48. Weinstein MP, Murphy JR, Reller LB, et al: The clinical significance of positive blood cultures: A comprehensive analysis of 500 episodes of bacteremia and fungemia in adults: II. Clinical observations with special reference to factors influencing prognosis. Rev Infect Dis 1983;5:54-70.Crossref
Maliwan, Nitaya;Zvetina, James R.
doi: 10.1001/archinte.1985.00360120048007pmid: N/A
Abstract A long-term follow-up of 263 patients with pulmonary Mycobacterium kansasii infection disclosed seven cases of mycetoma. We report the clinical manifestations of these patients. The incidence was less than that of tuberculosis. All mycetomas originated in large cavity lesions of inactive M kansasii infection. Most patients had received multiple antituberculous antibiotics, including rifampin. Five patients had died, two of underlying disease, one of invasive candidiasis following massive hemoptysis, one of surgical complication, and one of a possible invasive aspergillosis. (Arch Intern Med 1985;145:2180-2183) References 1. Bardana EJ Jr: The clinical spectrum of aspergillosis: II. Classification and description of saprophytic, allergic, and invasive variants of human disease. CRC Crit Rev Clin Lab Sci 1981;13:85-159.Crossref 2. Jewkes J, Kay PH, Paneth M, et al: Pulmonary aspergilloma: Analysis of prognosis in relation to haemoptysis and survey of treatment. Thorax 1983;38:572-578.Crossref 3. Varkey B, Rose HD: Pulmonary aspergilloma: A rational approach to treatment. Am J Med 1976;61:626-631.Crossref 4. British Thoracic and Tuberculosis Association: Aspergilloma and residual tuberculosis cavities: The results of a resurvey. Tubercle 1970;51:227-245.Crossref 5. Glimp RA, Bayer AS: Pulmonary aspergilloma: Diagnostic and therapeutic considerations. Arch Intern Med 1983;143:303-308.Crossref 6. Zvetina JR, Demos TC, Maliwan N, et al: Pulmonary cavitations in Mycobacterium kansasii: Distinctions from M tuberculosis. AJR 1984;143:127-130.Crossref 7. Gorse GJ, Fairshter RD, Friedly G, et al: Nontuberculous mycobacterial disease: Experience in a Southern California hospital. Arch Intern Med 1983;143:225-228.Crossref 8. Banks J, Hunter AM, Campbell LA, et al: Pulmonary infection with Mycobacterium kansasii in Wales, 1970-9: Review of treatment and response. Thorax 1983;38:271-274.Crossref 9. Gupta S, Grieco MH, Siegel L: Suppression of T-lymphocyte rosettes by rifampin: Studies in normals and patients with tuberculosis. Ann Intern Med 1975;82:484-488.Crossref 10. Humber DP, Nsanzumuhire H, Aluoch JA, et al: Controlled doubleblind study of the effect of rifampin on humoral and cellular immune responses in patients with pulmonary tuberculosis and in tuberculosis contacts. Am Rev Respir Dis 1980;122:425-436.
Velez, Ramon;Anderson, Lynda;McFall, Stephanie;Magruder-Habib, Kathryn
doi: 10.1001/archinte.1985.00360120052008pmid: N/A
Abstract • The effects of referral letters on increasing the likelihood of patients obtaining hypertension follow-up assessments are presented. Seventy-four patients with elevated diastolic blood pressure (between 95 and 120 mm Hg), who were administratively ineligible for longitudinal care from the Veterans Administration, were randomized into one of four groups: a patient letter; a physician letter; both patient and physician letters; or no letter (control group). No evidence of interaction between the patient and physician letters was found. Results revealed that nearly twice as many patients (63%) receiving the patient letter returned for a hypertension evaluation as compared with those who did not (33%). No difference was found between the physician letter and no physician letter conditions. These findings suggest that patient-directed referral letters can increase the likelihood of follow-up in both previously detected and newly detected cases. (Arch Intern Med 1985;145:2184-2187) References 1. Gillum RF, Stason WB, Weinstein MC: Screening for hypertension: A rational approach. Community Health 1978;4:67-72.Crossref 2. Sackett DL: The hypertensive patient: Findings and linking to clinical care. Can Med Assoc J 1979;120:1477-1480. 3. Wilber JA, Barrow JG: Hypertension: A community problem. Am J Med 1972;52:653-663.Crossref 4. Fletcher SW, Appel FA, Bourgeois MA: Improving emergency room patient follow-up in a metropolitan teaching hospital: Effect of a follow-up clerk. N Engl J Med 1974;291:385-388.Crossref 5. Gillum RF, Soloman HS, Kranz P, et al: Improving hypertension detection and referral in an ambulatory setting. Arch Intern Med 1978;138: 700-703.Crossref 6. Hypertension Detection and Follow-up Cooperative Group: Patient participation in a hypertension control program. JAMA 1979;239:1507-1514. 7. Theisen V, Caldwell JR, Erfurt JC, et al: A hospital-based screening referral and follow-up program for high blood pressure. Am J Public Health 1979;69:599-601.Crossref 8. Nugent CA, Gerlach BA: Hypertension control: The role of screening and referral to community physician. Prev Med 1980;9:569-577.Crossref 9. Stokes G, MacCarthy P, Frost G, et al: Management of hypertension newly detected by health screening. Med J Aust 1981;1:527-531. 10. Kass EH: Special clinics for hypertension: The role of the hypertension detection and follow-up programme. Br J Clin Pharmacol 1982;13:81-86.Crossref 11. Glass RI, Mirel R, Hollander G, et al: Screening for hypertension in the emergency department. JAMA 1978;240:1973-1974.Crossref 12. Edwards C: Blood pressure measurement by pharmacists. J R Coll Gen Pract 1981;31:674-676. 13. Wassertheil-Smoller S, Buur P, Blaufor MD: An evaluation of the utility of high blood pressure detection fairs. Am J Public Health 1978;68: 768-770.Crossref 14. Feussner J, Cockrell W: Medical care and entitlement in the Veterans Administration. NC Med J 1983;44:376-378. 15. Snedecor GW, Cochran WG: Statistical Methods , ed 6. Ames, Iowa State University Press, 1967, chap 16 . 16. Kleinbaum DG, Kupper LL, Morgenstern H: Epidemiologic Research Principles and Quantitative Methods . London, Lifetime Learning Publications, 1982, chap 15. 17. Martin D: The disposition of patients from a consultant general medical clinic. J Chronic Dis 1964;17:837-844.Crossref 18. Mroczek W: I'm sorry Mrs Jones, but you don't have hypertension. JAMA 1978;240:1991.Crossref
Timmis, Gerald C.;Westveer, Douglas C.;Hauser, Andrew M.;Stewart, James R.;Gangadharan, Vellappillil;Ramos, Renato G.;Gordon, Seymour
doi: 10.1001/archinte.1985.00360120056009pmid: N/A
Abstract • To test the hypothesis that myocardial infarction (MI) size rather than location determines the ventricular response to reperfusion, we studied 69 patients receiving intracoronary streptokinase within five hours of chest pain onset who displayed sustained reperfusion at 8.4±3.4 (SD) days. Twenty reperfusion failures served as controls. There were 31 patients with anterior MIs, 18 of which were estimated to be large based on an ejection fraction (EF) at reperfusion of less than 50%; 14 of 38 patients with inferior MIs also had large MIs. The EF increased at follow-up by 6.4%±2.6% in patients with large anterior MIs and by 8.2%±2.5% in those with large inferior MIs; in contrast, it increased by only 1.8%±2.6% in patients with small anterior MIs and significantly decreased by 5.8%±1.9% in patients with small inferior MIs. Six controls with large MIs (four anterior) displayed no change in EF; in 14 with small MIs (ten inferior), it fell slightly. There were no significant group differences in the number of diseased vessels, residual stenosis, or collaterals. It is concluded that MI size, not site, largely determines the ventricular functional response to early reperfusion; thus, patients with inferior MIs cannot be disqualified on this basis alone for thrombolytic therapy. (Arch Intern Med 1985;145:2188-2193) References 1. Mathey DG, Kuck KH, Tilsner V, et al: Nonsurgical coronary artery recanalization in acute transmural myocardial infarction. Circulation 1981; 63:489-497.Crossref 2. Cowley MJ, Hastillo A, Vetrovec GW, et al: Effects of intracoronary streptokinase in acute myocardial infarction. Am Heart J 1981;102:1149-1158.Crossref 3. Lee G, Amsterdam EZ, Low R, et al: Efficacy of percutaneous transluminal coronary recanalization utilizing streptokinase thrombolysis in patients with acute myocardial infarction. Am Heart J 1981;102:1159-1167.Crossref 4. Shah PK, Maddahi J, Berman D, et al: Intracoronary thrombolysis in early acute myocardial infarction improves biventricular function compared to conventional therapy, abstracted. Circulation 1981;64( (suppl IV) ):IV-194. 5. Hooghoudt TEH, Serruys PW, Reiber JHC, et al: The effect of recanalization of the occluded coronary artery in acute myocardial infarction on left ventricular function. Eur Heart J 1982;3:416-421. 6. Schwarz F, Faure A, Katus H, et al: Intracoronary thrombolysis in acute myocardial infarction: An attempt to quantitate its effect by comparison of enzymatic estimates of myocardial necrosis with left ventricular ejection fraction. Am J Cardiol 1983;51:1573-1578.Crossref 7. Rentrop P, Smith H, Painter L, et al: Changes in left ventricular ejection fraction after intracoronary thrombolytic therapy, abstracted. Circulation 1983;68( (suppl I) ):I-55-I-60. 8. Smalling RW, Fuentes F, Matthews MW, et al: Sustained improvement in left ventricular function and mortality by intracoronary streptokinase administration during evolving myocardial infarction. Circulation 1983; 68:131-138.Crossref 9. Timmis GC, Gangadharan V, Hauser AM, et al: Intracoronary streptokinase in clinical practice. Am Heart J 1982;104:925-938.Crossref 10. Rogers WJ, Hood WP Jr, Baxley WA, et al: Can improvement in LV function be predicted before reperfusion intervention in patients with AMI? abstracted. Circulation 1984;70( (suppl II) ):II-258. 11. Gilpin EA, Koziol JA, Madsen EB, et al: Periods of differing mortality distribution during the first year after acute myocardial infarction. Am J Cardiol 1983;52:240-244.Crossref 12. Simoons ML, Wijns W, Balakumaran K, et al: The effect of intracoronary thrombolysis with streptokinase on myocardial thallium distribution and left ventricular function assessed by blood-pool scintigraphy. Eur Heart J 1982;3:433-440. 13. Khaja F, Walton JA, Brymer JF, et al: Intracoronary fibrinolytic therapy in acute myocardial infarction. N Engl J Med 1983;308:1305-1311.Crossref 14. Anderson JL, Marshall HW, Bray BE, et al: A randomized trial of intracoronary streptokinase in the treatment of acute myocardial infarction. N Engl J Med 1983;308:1312-1318.Crossref 15. Verani MS, Tortoledo FA, Van Reet RE, et al: Intracoronary thrombolysis in acute myocardial infarction: Effects on function of myocardium at risk: Preliminary findings of a randomized trial, abstracted. J Am Coll Cardiol 1983;1:592. 16. Ritchie JL, Davis KA, William DL, et al: Radionuclide EF and tomographic 201-T1 defect size: Western Washington Randomized Intracoronary Streptokinase Trial (WWIST), abstracted. Circulation 1983; 68( (suppl III) ):III-121. 17. Leiboff RH, Katz RJ, Wasserman AG, et al: A randomized controlled trial of intracoronary streptokinase in acute MI: Preliminary (cautionary) observations, abstracted. Circulation 1982;66( (suppl II) ):II-334. 18. Geary GG, Smith GT, McNamara J: Quantitative effect of early coronary artery reperfusion in baboons. Circulation 1982;66:391-396.Crossref 19. Bergmann SR, Lerch RA, Fox KA, et al: Temporal dependence of beneficial effects of coronary thrombolysis characterized by positron tomography. Am J Med 1982;73:573-581.Crossref 20. Rogers WJ, Baxley WA, Hood WP, et al: Return of LV function following reperfusion in myocardial infarction: Importance of subtotal stenosis or intact collaterals, abstracted. J Am Coll Cardiol 1983;1:629. 21. Raizner AE, Tortoledo FA, Van Reet R, et al: Predominant benefit of thrombolytic therapy in patients with initially depressed left ventricular function: A randomized, controlled trial, abstracted. Circulation 1983;68 ( (suppl III) ):III-31. 22. Sanford CF, Corbett J, Nicod P, et al: Value of radionuclide ventriculography in the immediate characterization of patients with acute myocardial infarction. Am J Cardiol 1982;49:637-644.Crossref 23. Iskandrian AS, Lichtenberg R, Segal BL, et al: Assessment of jeopardized myocardium in patients with one-vessel disease. Circulation 1982;2:242-247.Crossref 24. Kalbfleisch H, Hort W: Quantitative study on the size of coronary artery supplying areas postmortem. Am Heart J 1977;94:183-188.Crossref 25. Becker LC, Schuster EH, Jugdutt BI, et al: Relationship between myocardial infarct size and occluded bed size in the dog: Difference between left anterior descending and circumflex coronary artery occlusions. Circulation 1983;3:549-557.Crossref 26. Ramos RG, Reddy C, Gangadharan V, et al: Should intracoronary thrombolytic therapy be performed in acute inferior infarction? abstracted. J Am Coll Cardiol 1984;3:526. 27. Smalling RW, Fuentes F, Hicks CH, et al: Effect of infarct location and reperfusion success on overall mortality with intracoronary streptokinase therapy, abstracted. J Am Coll Cardiol 1984;3:526. 28. Timmis GC, Gangadharan V, Hauser AM, et al: Intracoronary thrombolysis in a non-university hospital. Vase Med 1983;1:96-116. 29. Timmis GC, Gangadharan V, Mamman E, et al: Hemorrhage versus rethrombosis after coronary thrombolysis: The effect of delaying heparin, abstracted. J Am Coll Cardiol 1984;3:600. 30. Timmis GC, Gangadharan V, Ramos RG, et al: Hemorrhage and the products of fibrinogen digestion after intracoronary administration of streptokinase. Circulation 1984;69:1146-1152.Crossref 31. Greene DG, Carlisle R, Grant C, et al: Estimation of left ventricular volume by one-plane cineangiography. Circulation 1967;35:61-69.Crossref 32. Wisneski JA, Pfeil CN, Wyse DG, et al: Left ventricular ejection fraction calculated from volumes and areas: Underestimation by area method. Circulation 1981;63:149-151.Crossref 33. Peterson KL, Skloven D, Ludbrook P, et al: Comparison of isovolumic and ejection phase indices of myocardial performance in man. Circulation 1974;49:1088-1101.Crossref 34. Karsch KR, Lamm U, Blanke H, et al: Comparison of 19 quantitative models for assessment of localized left ventricular wall motion abnormalities. Clin Cardiol 1980;3:123-128. 35. Sato Y, Degawa T, Geft I, et al: Reperfusion makes the relationship of creatine kinase release to infarct size linear and allows accurate measurement of infarct size, abstracted. Circulation 1983;68( (suppl III) ):III-196. 36. Iskandrian AS, Lichtenberg R, Segal BL, et al: Assessment of jeopardized myocardium in patients with one-vessel disease. Circulation 1982;65:242-247.Crossref 37. Steele P, Kirch D, LeFree M, et al: Measurement of right and left ventricular ejection fractions by radionuclide angiocardiography in coronary artery disease. Chest 1976;70:51-56.Crossref 38. Schwarz F, Flameng W, Ensslen R, et al: Effect of coronary collaterals on left ventricular function at rest and during stress. Am Heart J 1978;95:570-577.Crossref 39. 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Walker, David H.;Lesesne, Henry R.;Varma, V. A.;Thacker, W. C.
doi: 10.1001/archinte.1985.00360120062010pmid: N/A
Abstract • Rocky Mountain spotted fever can present with predominantly abdominal symptoms including nausea, vomiting, diarrhea, and abdominal pain. Two elderly patients presented with an acute febrile illness and abdominal symptoms. Rash was not present initially. Workup disclosed cholelithiasis in one, and a thickened gallbladder wall surrounded by a sonolucent zone suggesting a pericholecystic abscess was found by ultrasonography in the other. Both patients underwent emergency laparotomy, with cholecystectomy in both and appendectomy in one. Both patients died several days postoperatively. Pathologic specimens reviewed later showed that multiple blood vessels of the gallbladder and the appendix were infected with Rickettsia rickettsii, and there was focal vascular thrombosis and hemorrhage. These documented direct rickettsial infections and lesions in the blood vessels of abdominal viscera suggest the basis for the abdominal symptoms in Rocky Mountain spotted fever. (Arch Intern Med 1985;145:2194-2196) References 1. Vianna NJ, Hinman AR: Rocky Mountain spotted fever on Long Island: Epidemiologic and clinical aspects. Am J Med 1971;51:725-730.Crossref 2. Sexton DJ, Burgdorfer W: Clinical and epidemiologic features of Rocky Mountain spotted fever in Mississippi, 1933-1973. South Med J 1975;68: 1529-1535.Crossref 3. Middleton DB: Rocky Mountain spotted fever: Gastrointestinal and laboratory manifestations. South Med J 1978;71:629-632.Crossref 4. Hattwick MAW, Retailliau H, O'Brien RJ, et al: Fatal Rocky Mountain spotted fever. JAMA 1978;240:1499-1503.Crossref 5. Kaplowitz LG, Fischer JJ, Sparling PF: Rocky Mountain spotted fever: A clinical dilemma. Curr Clin Top Infect Dis 1981;2:89-108. 6. Walker DH, Cain BG: A method for specific diagnosis of RMSF on fixed, paraffin-embedded tissue by immunofluorescence. J Infect Dis 1978;137:206-209.Crossref 7. Rothenberg R, Sonenshine DE: Rocky Mountain spotted fever in Virginia: Clinical and epidemiologic features. J Med Entomol 1970;7:663-669. 8. Davis AE Jr, Bradford WD: Abdominal pain resembling acute appendicitis in Rocky Mountain spotted fever. JAMA 1982;247:2811-2812.Crossref 9. Jiminez J, Byrne WF, Seibert JJ, et al: Gastrointestinal symptoms in Rocky Mountain spotted fever: Histopathologic finding of ulcerative enteritis with vasculitis. Clin Pediatr 1982;21:581-584.Crossref 10. Benson M, Walker DH: Rocky Mountain spotted fever in the differential diagnosis of the acute abdomen. Contemp Surg 1984;24:79-83. 11. Rocky Mountain spotted fever: United States, 1982. MMWR 1983;32: 229-232. 12. Randall MB, Walker DH: Rocky Mountain spotted fever: Gastrointestinal and pancreatic lesions and rickettsial infection. Arch Pathol Lab Med 1984;108:963-967. 13. Becker FE: Investigations on Rocky Mountain spotted fever in Colorado. J Infect Dis 1926;39:81-89.Crossref
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