The American journal of medicine
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Pharyngitis, bronchitis, and pneumonia represent the most common respiratory tract infections. With a view to establishing effective management strategies, the origins of these illnesses and the diagnostic techniques that have been developed to discover them are reviewed. Therapeutic regimens with documented efficacy are outlined with emphasis on specific rather than empiric treatment. Although many respiratory tract pathogens remain exquisitely sensitive to penicillin, the emergence of resistant strains underscores the need for safe and effective alternative therapies.
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Of the four categories of oral analgesics, three have been available since the 19th century. Although adequate doses of the more potent oral opioids such as morphine and methadone are effective even in severe pain, the commonly used "weak" narcotics such as codeine and propoxyphene are no more effective than usual doses of aspirin or acetaminophen. Furthermore, the opioids produce gastrointestinal and central nervous system adverse effects, and, during long-term administration, tolerance may develop and there is a risk of drug dependence. ⋯ The fourth category of oral analgesics constitutes the most important recent development in pain management with analgesic drugs: the newer peripherally acting, nonsteroidal anti-inflammatory analgesics, some of which are clearly more efficacious than aspirin or acetaminophen and compare favorably not only with full doses of narcotic combination products but even, in some cases, with strong injectable opioids. On repeated dosing, some nonsteroidal anti-inflammatory drugs are better tolerated than aspirin and some have a much longer duration of analgesic effect than aspirin or acetaminophen. Further study is needed to compare nonsteroidal anti-inflammatory drugs among themselves and to determine their value in chronic pain and in combination therapy.
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Review Case Reports
Acute paraplegia: a presenting manifestation of aortic dissection.
Two patients who presented with acute paralysis of the lower extremities as an initial manifestation of aortic dissection are described. The first patient had transient chest pain followed by flaccid paralysis of her lower extremities and severe back pain. In the second patient, sudden paralysis of both legs developed without pain of any sort. ⋯ Both patients had a proximal (type I or A) aortic dissection. The first patient's entrance tear in the aortic intima was just above the aortic valve with antegrade propagation, whereas in the second patient, the entrance tear was at the aortic isthmus, with both antegrade and retrograde dissection. Acute cardiac tamponade resulted in sudden deterioration and death in both patients, before any therapeutic intervention could be entertained.
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Stress-related mucosal damage of the upper gastrointestinal tract occurs in the majority of critically ill patients. The more severe the underlying disease, the greater the chance that mucosal damage and subsequent bleeding will develop. Clinical outcome is determined by the type and severity of the underlying illness; however, cases with severe gastric damage, as diagnosed by endoscopic examination or by bleeding, have the poorest prognoses. ⋯ Vigorous acid suppression with prolonged periods of pH control may be necessary to treat stress-related mucosal damage and to prevent bleeding. Treatment modalities in current use include antacids, cimetidine, and other histamine (H2)-receptor antagonists, and, more recently, sucralfate. Current evidence indicates that antacids, given hourly and titrated to a present pH goal, or primed continuous infusion of cimetidine are the most efficacious regimens in maintaining intragastric pH control.