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1/14. Recognizing factitious hypoglycemia in the family practice setting.

    BACKGROUND: Factitious hypoglycemia is a deliberate attempt to induce a low serum glucose level using either insulin or oral hypoglycemic agents. Sulfonylurea-induced hypoglycemia is more common than incidents of insulin abuse, and hypoglycemia caused by these oral agents is biochemically indistinguishable from insulinoma. methods: We describe a case of factitious hypoglycemia resulting from insulin abuse in an adult diabetic patient, review the essentials of glucose homeostasis, and describe diagnostic tests that allow a differential diagnosis. RESULTS AND CONCLUSION: Factitious hypoglycemia is associated with a higher incidence of suicide, depression, and personality disorders. Insulin-induced hypoglycemia can be detected by an insulin to c-peptide ratio that is greater than 1.0. In the absence of proof to the contrary, insulinoma should be considered the cause of hypoglycemia until another diagnosis is established. The generally poor prognosis for patients with factitious hypoglycemia underscores the importance of early recognition of factitious disorders.
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2/14. Ring keratitis from topical anaesthetic misuse.

    BACKGROUND: Topical anaesthetic abuse is now an established differential diagnosis of ring keratitis. Published evidence suggests that this condition often has a poor prognosis, with the eyes sometimes requiring penetrating keratoplasty or the patient becoming blind. METHOD: A case of topical anaesthetic abuse and its subsequent management is presented. Ocular examination including pachymetry and specular microscopy is reported. RESULTS: The cornea made an excellent recovery, allowing a visual acuity of 6/6. Pachymetry showed corneal thickening and specular microscopy demonstrated a decreased cell count in the affected eye. CONCLUSIONS: With prompt recognition and appropriate treatment the prognosis for these cases can be excellent. However, there is evidence to suggest permanent cellular damage to the endothelium.
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3/14. munchausen syndrome presenting acutely in the emergency department.

    munchausen syndrome is a rare psychiatric disorder in which patients purposely harm themselves to gain medical attention. These patients may present to unsuspecting emergency department (ED) staff members with life-threatening signs and symptoms. We report a case of munchausen syndrome in which a young man with ties to the medical community and a history of substance abuse presented to our ED with refractory hypoglycemia and a dilated right pupil. The patient required large amounts of dextrose, endotracheal intubation, mechanical ventilation, and admission to the intensive care unit. Further investigation revealed that he had purposely injected himself with a large dose of insulin and instilled atropine drops in his right eye for the purpose of seeking hospitalization. The history, details, diagnosis, treatment, and prognosis are discussed in the context of this case.
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4/14. Acute rhabdomyolysis and renal failure in hiv-infected patients: risk factors, presentation, and pathophysiology.

    rhabdomyolysis is a common cause of acute renal failure and may be related to a variety of predisposing factors. This entity has been increasingly recognized in hiv-infected individuals and is an important cause of morbidity and mortality. We present a series of seven hiv-positive patients admitted with rhabdomyolysis over a 5-year period; three developed acute renal failure. Infections and substance abuse were the most common risk factors identified; an average of three predisposing factors was present in each case. All patients showed resolution of creatinine phosphokinase (CPK) elevation and serum creatinine returned to the normal range in the three patients who developed renal insufficiency; however, all patients required prolonged hospitalization and one patient died of sepsis. The pathophysiological mechanisms of muscle injury in our patients are reviewed and their bearing on prognosis discussed. It is concluded that clinicians should have a high index of suspicion for the development of rhabdomyolysis in hiv-infected patients with a combination of noncompliance with medical therapy and/or substance abuse and acute infection. With comprehensive supportive care, the prognosis of acute rhabdomyolysis in this population may be reasonably good.
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5/14. Anaesthetic management of a parturient with myocardial infarction related to cocaine use.

    cocaine abuse is common among parturients with an incidence of 11.8 to 20%. myocardial infarction is a rare and lethal event during pregnancy with an incidence of 1 in 10,000 pregnancies. We present the anaesthetic management of a parturient of 36 wk gestation who suffered a myocardial infarction nine hours before delivery which was temporally related to "crack" cocaine use. The patient's cardiovascular system became unstable following cocaine use, and she required mechanical ventilatory support and pharmacologic stabilization guided by invasive haemodynamic monitoring. This patient survived a non-Q wave myocardial infarction, but the prognosis of peripartum myocardial infarction remains poor with a mortality rate of 30-40% which is increased if the infarction occurs in the third trimester or postpartum period. The optimal mode and timing of delivery after myocardial infarction is unresolved. The association between cocaine use and myocardial infarction was first described in 1982, and cocaine remains unique among local anaesthetics in its ability to compromise the cardiovascular system through both sympathomimetic effects and vasoconstrictive effects on coronary arteries. Because of the prevalence of substance abuse, cocaine use should be considered in the differential diagnosis of sudden cardiovascular compromise in parturients.
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6/14. Encephalopathy due to toluene sniffing. Report of a case with magnetic resonance imaging.

    A 27-year-old man with a 10-year history of toluene abuse developed dementia, cerebellar ataxia, dysarthria and pyramidal signs. magnetic resonance imaging (MRI) revealed atrophy of the cerebrum, corpus callosum, cerebellum and brainstem. The internal capsule showed abnormal intensity. Chronic toluene abuse may affect not only the cerebral and cerebellar cortex or brainstem but also the subcortical cerebral white matter. MRI may be a sensitive tool to use in evaluating the severity and prognosis of the neurological syndrome resulting from toluene abuse.
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7/14. cocaine-associated acute myoglobinuric renal failure.

    PURPOSE: Abuse of cocaine is associated with serious medical complications involving the heart, central nervous system, and gastrointestinal tract. Renal complications appear to be uncommon. We describe herein four patients with rhabdomyolysis and acute myoglobinuric renal failure temporally related to cocaine use. case reports: Acute cocaine intoxication was the most common presentation and rhabdomyolysis was an unexpected finding. Renal failure progressed rapidly in all patients, necessitating dialysis in two. The prognosis was good, and all patients survived. The mechanism of cocaine injury is unclear; possibilities include increased muscle activity, muscle compression, hyperthermia, and vasospasm with muscle ischemia. CONCLUSION: rhabdomyolysis with acute renal failure should be recognized as a possible complication of cocaine abuse.
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8/14. Left-sided endocarditis due to pseudomonas aeruginosa. A report of 10 cases and review of the literature.

    Ten confirmed cases of left-sided endocarditis due to pseudomonas aeruginosa were reported in detail and the English literature was reviewed. In recent years, venous access (usually illicit) has been the major predisposing factor to this infection and abuse of pentazocine and tripelennamine has been particularly associated with endocarditis due to this organism. This infection involves previously damaged as well as normal valves. The development of congestive heart failure did not adversely affect the prognosis of this infection. However, the development of azotemia was associated with a greater likelihood of a fatal outcome. In the current series, deaths were due to uncontrolled infection. This often occurred despite inhibitory and bactericidal activity in serum generally considered adequate for treatment of endocarditis. Medical treatment alone rarely produced cure of infection. Our experience with a high frequency of major vessel embolization (4/10) and the improved survival after medical/surgical treatment suggests that prompt valve replacement combined with high doses of an aminoglycoside plus carbenicillin or ticarcillin provide the best opportunity for successful outcome in patients with left-sided endocarditis due to P. aeruginosa.
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9/14. Lymphocytic interstitial pneumonia in patients at risk for the acquired immune deficiency syndrome.

    Three patients with the acquired immune deficiency syndrome (AIDS) or aids-related complex and lymphocytic interstitial pneumonia are reported. All patients presented with progressive dyspnea, nonproductive cough, fever, anorexia, weight loss, and arterial hypoxemia. Chest roentgenograms exhibited bilateral diffuse reticular-nodular densities. The diagnosis of lymphocytic interstitial pneumonia was made by fiberoptic bronchoscopy or open lung biopsy. Two patients were treated with corticosteroids, with significant improvement. The third patient died of pneumonia due to pneumocystis carinii six months after the diagnosis of lymphocytic interstitial pneumonia was established. serum antibodies to human immunodeficiency virus (hiv) were demonstrable in the two patients in whom the test was performed. Lymphocytic interstitial pneumonia is probably another pulmonary manifestation of AIDS or aids-related complex. Although the clinical presentation may be identical to the more common opportunistic infections, the treatment differs, and the prognosis may be better.
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ranking = 1
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10/14. Long-term prognosis in addiction on sedative and hypnotic drugs analyzed with the Cox regression model.

    The prognosis of 221 patients first admitted in 1941-1954 for dependence on sedative-hypnotic drugs was determined in a record-linkage and interview study concluded in 1984. Different outcomes were related to admission characteristics by means of the Cox proportional hazards regression model. An excess of unnatural deaths was noted; suicides in 11% of the men and 23% of the women. Of those with primary sedative-hypnotic dependence, 46% continued to abuse drugs till death or follow-up, and of those with a primary or concomitant alcohol abuse 72%. An unfavorable outcome was significantly related to primary psychiatric symptoms before the first admission, concomitant alcohol abuse, familial drug and alcohol abuse and health care occupation.
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ranking = 5
keywords = prognosis
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