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Biomedical subjects

G R Corey

Publications and source records attributed to G R Corey.

At least 73 records · Page 4Linked to original sources
PubMed1993

Brazilian spotted fever in Espirito Santo, Brazil: description of a focus of infection in a new endemic region.

Although Brazilian spotted fever is known to occur in several adjacent states, infection with spotted fever group (SFG) rickettsiae has not previously been documented in the Brazilian state of Espirito Santo. We report a cluster of two proven and four suspected cases of Brazilian spotted fever in a small valley near Colatina, Espirito Santo. Four patients died without confirmatory serologic or pathologic studies. The two surviving patients had serologic and/or pathologic evidence of infection with SFG rickettsiae. Results of a survey done in 1991 confirmed the presence of antibodies reactive with SFG rickettsiae in the serum of dogs living in this region. Two of 25 dogs had elevated microimmunofluorescent antibody titers (1:64 and 1:256). Both seropositive dogs were pets of the index cases and lived in the valley where all six human cases were presumed to have acquired their infections. These cases and the results of the canine serosurvey suggest that a focus of virulent disease exists in an area not previously known to be endemic for SFG rickettsiae.

Adult↗
PubMed1992

Assessing housestaff diagnostic skills using a cardiology patient simulator.

OBJECTIVE: To assess the cardiovascular physical examination skills of internal medicine housestaff. DESIGN: Cross-sectional assessment of housestaff performance on three valvular abnormality simulations conducted on the cardiology patient simulator, "Harvey." Evaluations were done at the beginning (session I) and end (session II) of the academic year. SETTING: Duke University Medical Center internal medicine training program. SUBJECTS: Sixty-three (59%) of 107 eligible internal medicine housestaff (postgraduate years 1 through 3) agreed to participate and completed session I; 60 (95%) completed session II. MEASUREMENTS: All volunteers were tested on three preprogrammed simulations (mitral regurgitation, mitral stenosis, and aortic regurgitation). RESULTS: The overall correct response rates for all housestaff were 52% for mitral regurgitation, 37% for mitral stenosis, and 54% for aortic regurgitation. No difference was noted in correct response rates between sessions I and II. For mitral regurgitation, correct assessment of the contour of the holosystolic murmur predicted a correct diagnosis (P = 0.002). For mitral stenosis, identification of an opening snap and proper characterization of the mitral area diastolic murmur predicted a correct diagnosis (P < 0.0001). No individual observations were noted for the aortic regurgitation simulation, whose identification by the housestaff was associated with a correct diagnosis. CONCLUSIONS: Housestaff had difficulty establishing a correct diagnosis for simulations of three common valvular heart diseases. Accurate recognition of a few "key" observations was associated with a correct diagnosis in two of the three diseases. Teaching housestaff to elicit and interpret a few critical signs accurately may improve their physical diagnosis abilities.

Cardiology↗
PubMed1992

Diagnosis and management (by subxiphoid pericardiotomy) of large pericardial effusions causing cardiac tamponade.

To determine the clinical features, course and outcome of patients with cardiac tamponade, 57 consecutive patients with new, large pericardial effusions were prospectively studied. Twenty-five patients (44%) developed cardiac tamponade with venous hypertension and a pulsus paradoxus greater than 10 mm Hg. Electrocardiography, radiographic studies and echocardiography did not differentiate patients with and without tamponade. All 57 patients underwent thorough diagnostic evaluation followed by subxiphoid pericardial biopsy and drainage. A diagnosis was obtained in 53 patients (93%). Collagen vascular disease was significantly more frequent in the 25 patients with than in the 32 without cardiac tamponade (24 vs 3%; p less than 0.05). The frequency of malignant and uremic effusions was equal in both groups, whereas radiation-induced effusions seldom produced tamponade. At 1-year follow-up, 3 patients (12%) with tamponade had recurrent effusions, and 1 needed reoperation. This was not significantly different from the 32 patients without tamponade. Twelve-month mortality was also similar in both groups (36 vs 44%). This prospective series disclosed several unexpected findings: (1) Cardiac tamponade occurred in almost 50% of patients with new large pericardial effusions; (2) both malignancy and collagen vascular disease occurred with equal frequency as etiologies, whereas radiation-induced tamponade was unusual; (3) thorough clinical evaluation resulted in few idiopathic etiologies; and (4) subxiphoid pericardiotomy was effective for both diagnosis and therapy of tamponade.

Cardiac Tamponade↗
PubMed1992

Rocky Mountain "spotless" and "almost spotless" fever: a wolf in sheep's clothing.

In 10 (10.8%) of 93 laboratory-confirmed or probable cases of Rocky Mountain spotted fever seen at Duke University Medical Center from 1969 to 1991, illness without rash or fleeting or atypical skin eruptions were noted. Data from these 10 cases and 33 similar previously reported cases of Rocky Mountain "spotless" or "almost spotless" fever support the premise that human Rickettsia rickettsii infection has a broader spectrum than that indicated by its classic description. Sixty-one percent of patients with Rocky Mountain spotless or almost spotless fever have been men. Two-thirds have been black. Although in some cases the absence of rash may be due to the prompt institution of therapy with chloramphenicol or tetracycline, in others long delays in recognition of the disease and treatment occurred, resulting in the deaths of 53% of patients. On the basis of outcome in the cases reviewed, empirical administration of chloramphenicol or a tetracycline to selected patients is justifiable (including those patients with severe organ dysfunction), even if they have no rash, a transient rash, or a rash of unusual distribution. Indeed, without such therapy, patients with spotless or almost spotless fever may die. Recognizing such atypical cases is analogous to seeing a wolf in sheep's clothing--intuition, experience, knowledge, and a high index of suspicion are required.

Adolescent↗
PubMed1992

Subxiphoid pericardiotomy in the diagnosis and management of large pericardial effusions associated with malignancy.

To determine the safety, diagnostic value, and clinical outcome of patients with malignancy undergoing subxiphoid pericardiotomy for large pericardial effusions, we prospectively studied 25 consecutive patients with malignancy and new, large pericardial effusions diagnosed by echocardiography. Twenty-two of the 25 operations were done under local anesthesia, and no patient died at surgery. Pericardial fluid cytology revealed malignant cells in 11 patients (44 percent), while tumor was seen in only five (45 percent) of these 11 patients on pathologic examination. The remaining 14 patients showed no evidence of pericardial invasion with tumor. Evidence of intrathoracic disease by CT or MRI scanning, tamponade, a sanguineous pericardial fluid character, and an elevated serum and pericardial fluid lactate dehydrogenase level all were suggestive of malignant invasion of the pericardium. All 25 patients were followed at least 12 months postoperatively. Effusions recurred in three patients (12 percent), and one patient required reoperation. Overall mortality was 72 percent with a 91 percent (10 of 11) mortality for those with malignant effusions and a 57 percent (8 of 14) mortality for those with nonmalignant effusions. Diagnostically, subxiphoid pericardiotomy has little advantage over examination of pericardial fluid alone in this group of patients. Therapeutically, however, it is a low morbidity procedure which is safe and effective in treating patients with malignancy and large pericardial effusions.

Cardiac Tamponade↗
PubMed1991

Gonococcal osteomyelitis. Case report and review of the literature.

We report the 11th case of gonococcal osteomyelitis in the postantibiotic era. This case demonstrates the classic presentation of osteomyelitis associated with gonorrhea, a subacute illness with minimal systemic symptoms. In addition, we present radiologic evidence of the pathogenesis of this unusual osteomyelitis from a contiguous joint infection.

Adult↗
PubMed1989

Gonococcal endocarditis: a new look at an old disease.

Gonococcal endocarditis, like other gonococcal infections, occurs mainly in the young adult population. The onset of the disease tends to be subacute with an infrequent history of preceding infection or the discovery of a local source of infection. The presenting symptoms and signs fail to differentiate it from other types of endocarditis. Blood cultures are often negative for the first several days. Echocardiography has been useful in helping establish a diagnosis, and survival is favorable with medical and surgical therapy if the diagnosis is made early in the course of the disease. The disease can be quite aggressive, however, and lead to rapid clinical deterioration from valvular destruction and congestive heart failure. As with other forms of endocarditis, deterioration is an indication for aggressive management with early valve replacement.

Adult↗
PubMed1987

Extra-intestinal manifestations of salmonella infections.

While salmonellosis is often considered to affect primarily the gastrointestinal tract, infection at other sites may occur, producing characteristic clinical syndromes. We reviewed cases from our institutions and the literature on focal manifestations of salmonella infections. In the past, most extra-intestinal salmonella infections were caused by S. choleraesuis; however, we found S. typhimurium to be the predominant serotype. The mortality rate for patients in our series was considerably lower than the rate described for focal infections in other reviews. This may in part be due to lower proportion of infections due to S. choleraesuis, improved microbiologic and diagnostic techniques, increased use of ampicillin, and improved surgical techniques. Salmonella endocarditis usually occurs in patients with preexisting heart disease. Unlike other salmonella infections, S. choleraesuis is the most frequent serotype. Salmonella endocarditis is often very destructive, with a fatality rate of 70%. Nonvalvular (mural) endocarditis occurs in one-fourth of patients and survival has not been reported. While antibiotic therapy should be tried initially, if response is not prompt the clinician should look for an associated site of infection (intra- or extra-cardiac abscess), which will often require surgery. Salmonella pericarditis often presents with cardiac or pulmonary symptoms, but typical signs of pericardial disease (pulsus paradoxus, friction rub) or characteristic electrocardiographic changes (low voltage, elevated ST segments) are uncommon. Early diagnosis, before infection involves other areas of the heart, is crucial for survival. In addition to antibiotic therapy, pericardiocentesis or pericardiectomy is required. Salmonella may infect the peripheral or visceral arteries, but the abdominal aorta is the most frequent site of vascular infection. Most patients are men over age 50 with preexisting atherosclerosis of the aorta who do not have a previous history of gastroenteritis. About one-fourth of patients have associated lumbar osteomyelitis. No patients have been reported to survive with medical therapy alone. Specific guidelines for surgical removal of infected aneurysms have been proposed and these (in addition to increased use of ampicillin) may be responsible for higher survival rates in recent years. Due to the high incidence of relapses, postoperative blood cultures should be done routinely. Arterial infection should be considered in any elderly patient with salmonella bacteremia especially with prolonged fever or bacteremia after an "adequate course" of antibiotic therapy.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗
PubMed1985

Cytomegalovirus infection in the normal host.

CMV mononucleosis often resembles EBV infectious mononucleosis; however, certain features of the history and physical may help to distinguish CMV from EBV. While CMV mononucleosis is usually self-limited, certain laboratory abnormalities may persist for months or years after the patient has recovered. Previous reports on CMV in the non-immunocompromised host have rarely described systemic complications. We have reviewed 10 cases of CMV with systemic manifestations at one institution over a 15-year period. These patients had prolonged fevers (often greater than three weeks) and the diagnosis was often unsuspected during the early part of the illness. While two patients required mechanical ventilation, all patients had self-limiting disease and survived. When CMV is suspected and diagnosed early in the course, numerous diagnostic (and potentially dangerous) tests can be avoided in a viral illness in which prolonged fever is common.

Adolescent↗
PubMed1984

Single and multiple pyogenic liver abscesses. Natural history, diagnosis and treatment, with emphasis on percutaneous drainage.

The presenting features, modes of treatment and clinical course were reviewed for 55 patients with pyogenic liver abscess, seen at Duke University Medical Center over a 15-year period. Thirty-three patients had a solitary abscess and 22 had multiple abscesses. Most patients were between the ages of 40 and 60 years. Males predominated, 2.4:1. Major underlying conditions included biliary tract disease, malignancy and colonic disease. Eight patients, each with a solitary abscess, had no identifiable underlying condition. Symptoms and signs were nonspecific: fever, chills, focal abdominal tenderness and hepatomegaly were common. A raised serum alkaline phosphatase level was the most consistent abnormal laboratory finding. CT with contrast enhancement, radioisotope scanning and ultrasonography all accurately defined solitary hepatic abscesses. However, CT scan was more successful than other imaging techniques in detecting multiple abscesses. In seven patients the diagnosis was made only at laparotomy. Overall, a diagnosis of liver abscess was made in 50 living patients (91%). Microorganisms were recovered from pus and/or blood cultures of 44 patients (80%). Most common were enteric gram-negative facultative rods, anaerobic gram-negative rods, and microaerophilic streptococci. Single abscesses were more likely than multiple abscesses to contain more than one organism. All patients received antibiotics; the choice of antibiotic does not appear to be critical provided the regimen has a broad spectrum including activity against anaerobes. Surgical or percutaneous drainage was successful when attempted in all patients with a single abscess, but the outcome was less favorable in those with multiple abscesses. Percutaneous drainage is currently replacing open operative drainage as the method of choice. Overall mortality in patients with single abscesses was 15% (5/33) and in those with multiple abscesses 41% (9/22).

Adolescent↗
PubMed1983

Late appearance of skin rash in Rocky Mountain spotted fever.

Late appearance of a skin rash in Rocky Mountain spotted fever is associated with a high mortality. Our patient's rash appeared 14 days after the onset of illness, during his recovery. In endemic areas one must rely on clinical clues other than rash to raise the suspicion of Rocky Mountain spotted fever. The combination of fever, headache, myalgias, marked left shift in the differential white blood cell count, severe thrombocytopenia, and hyponatremia all help to suggest the correct diagnosis early in the course of the illness.

Adult↗