Arch Intern Med
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A review of emergency department visits during a 2-year period and before and after the liberation of physicians from a requirement of gatekeeping for some patients during the night showed no significant increases in the use or costs of services to our Medicaid enrollees for all but children under 6 years of age between 10 PM and midnight. We recommend that a more humane and practical view be taken of middle-of-the-night gatekeeping requirements for physicians functioning in managed-care environments. We also suggest, as many hospitals have already learned, that the costs of emergency department services for Medicaid patients can be reduced and that care may be enhanced by the offering of 24-hour urgent care services at or near the emergency department.
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Case Reports
Neuroleptic malignant syndrome in Parkinson's disease after withdrawal or alteration of dopaminergic therapy.
Neuroleptic malignant syndrome is characterized by altered consciousness, fever, extrapyramidal signs, autonomic instability, elevated creatine kinase level, and leukocytosis. Although originally described in patients receiving neuroleptic drugs, this syndrome may also occur in patients with Parkinson's disease during withdrawal or reduction of levodopa therapy or other dopaminergic drug therapy. ⋯ These cases illustrate the variety of circumstances in which alteration of therapy with dopaminergic drugs can cause this syndrome and the relative unfamiliarity of the neuroleptic malignant syndrome-levodopa relationship among physicians who do not treat large numbers of patients with Parkinson's disease. An understanding of the role of brain dopamine in the pathogenesis of neuroleptic malignant syndrome and an appreciation of the great variety of drugs whose manipulation can result in this potentially fatal syndrome will aid its proper and timely recognition, especially when the offending pharmacologic manipulation does not involve neuroleptic drugs.
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Review Case Reports
Pneumothorax complicating small-bore feeding tube placement.
Small-bore Silastic feeding tubes are being used with increasing frequency for short- and long-term enteral hyperalimentation. We present three cases where these flexible tubes were passed into the tracheobronchial tree and then out into the pleural space. The result in each case was a pneumothorax or hydropneumothorax. ⋯ The traditional methods of assessing proper nasogastric tube placement are inadequate when applied to these small tubes. Only a chest roentgenogram can assure placement in the stomach. Education of hospital staff on methods to avoid malposition of feeding tubes has resulted in an absence of pulmonary complications over a subsequent 1-year period.
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We describe a case of severe refractory hypoglycemia secondary to topical salicylate intoxication. A 72-year-old man with psoriasis and end-stage renal disease was treated with a topical cream containing 10% salicylic acid. The patient presented with encephalopathy and subsequently developed hypoglycemia refractory to infusions of large amounts of glucose. ⋯ Salicylate is well absorbed across normal and diseased skin. Salicylate markedly impairs gluconeogenesis and increases glucose utilization, resulting in hypoglycemia. To our knowledge, this is the first article on hypoglycemia due to the application of topical salicylate.
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The study objective was to describe the clinical, biologic, and hemodynamic features of adult overwhelming meningococcal purpura and to examine the prognostic factors by multivariate analysis at the time of admission to the intensive care unit. Thirty-five patients (greater than or equal to 13 years of age) with meningococcal infection, circulatory shock, and generalized purpuric lesions of abrupt onset were recorded in eight intensive care units from 1977 to 1989. The patients were young (mean age, 26.6 years; range, 13 to 68 years) and had been previously healthy. ⋯ Stepwise regression analysis showed that low fibrinogen level (less than or equal to 1.5 g/L) was the sole adverse prognostic variable (odds ratio = 2, 95% confidence interval, 1.5 to 2.7). Adult overwhelming meningococcal purpura is still associated with high mortality and morbidity. Low fibrinogen level at time of admission may permit early recognition of the most severely ill patients.