Table Of Content

7land medical journal: MMJ.(IM) 8, no 1 (Jan-Feb 1999) 3 - General Collection MA76M eived 02-19-1999 al Journal A ICLES ts after ation of shoulder ! challenges of c cing: an illustr; Spinal subdur; a rare ' i ' tion cture property of the NATIONAL & ir.E: 9 5^- fhePru IHSE9 LIBRARY OF im mM MEDICINE =• , i». i*L ction caused by er the ingestion plastic clip 176802 aw VaSHHIHa OTMTQ WOOd '88 0018 l72t70l70S WI SadOOHd IVIdHS 23 3NI0IQ3W 30 Ad^dOIl 1VN0I1VN — — C90 890 20 802 1I0IQ-8 **-***• January/February 1999 a career on... Concepts uilfm company on... Featuring these latest products... • Healthcare Business Office Package (BOP). A comprehensive commercial liability insurance package for all aspects of your office-based practice. • Med-Rite™. A comprehensive risk improvement program designed to identify and make recommendations for your areas of risk within your office-based practice. 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Signature_ Maryland Medical Journal JANUARY/FEBRUARY 1999 • VOL 48 NO 1 Editor Marion Friedman, M.D. ORIGINAL ARTICLES Editorial Board Members Long-term functional results after Safuh Attar, M.D. manipulation of the frozen shoulder. 7 Timothy D. Baker, M.D. Jerome P. Reichmister, M.D., and Steven L. Friedman, M.D. John Buckley, M.D. Vincenzo De Masi, M.D. The challenges of cardiac pacing: an illustrative case.12 Michael D. Freedman, M.D. Mahmood Alikhan, M.D., MPH, FACC, and James H. Biddison, M.D., FACC David S. Freitag, M.D. Barry H. Friedman, M.D., J.D. Spinal subdural hematoma: Eve J. Higginbotham, M.D. a rare complication of lumbar puncture Perry Hookman, M.D. Case report and review of the literature.15 Norris L. Horwitz, M.D. Leonard E. Egede, M.D., Howard Moses, M.D., and Henry Wang, M.D. Sanford M. Markham, M.D. Michael Monias, M.D. The Prion Dementias.18 Chris Papadopoulos, M.D. Constantine Lyketsos, M.D., M.H.S. Thomas R. Price, M.D. Amalia E. Seiguer, M.D. Small bowel obstruction caused by Charles E. Wiles III, M.D. intussusception after the ingestion of a plastic clip.23 Eva Zinreich, M.D. Douglas P. Beall, M.D., Fintan Regan, M.D., and Ba Nguyen, M.D. Editorial Advisory Members A community care initiative: Maryland and Hopkins students take to the streets in Baltimore City 26 Bart Chernow, M.D. Jessie McCary, Elisabeth Schainker, and Peter Liu Val Hemming, M.D. Donald E. Wilson, M.D. Theodore E. Woodward, M.D. Maryland Medical Journal January/February 1999 3 MMJ Maryland Medical Journal DEPARTMENTS 1211 Cathedral Street Baltimore, MD 21201 410-539-0872 Letters to the Editor 5 1-800-492-1056 (toll-free in MD) FAX 410-547-0915 Maryland Medicine in Review Board of Trustees President Allan D. Jensen, M.D. Books, etc. 33 President-Elect Wayne C. Spiggle, M.D. Continuing Medical Education Review Committee Update.35 Immediate Past President Thomas E. Allen, M.D. What Your Patients May Be Reading.37 Speaker of the House Louis C. Breschi, M.D. Epidemiology and Disease Control Newsletter 39 Vice Speaker of the House Hilary T. O'Herlihy, M.D. Secretary J. Ramsay Farah, M.D. MISCELLANY Treasurer Albert L. Blumberg, M.D. CME Programs.43 AM A Delegation Representative George Malouf, Sr., M.D., AMA Physician's Recognition Award.46 Trustees Willie C. Blair, M.D. James Chesley, M.D. James E. Kelly, D.O. Classified Advertising.48 Allan T. Leffler II, M.D. Peter C. Lizas, M.D. Mark S. Seigel, M.D. Howard M. Silby, M.D. Catherine N. Smoot-Haselnus, M.D. Jos W. Zebley, M.D. Executive Director T. Michael Preston Managing Editor Vivian D. Smith Graphic Design Copyright0 1999. MMJ Vol 48, No 1. Maryland Medical Journal USPS 332080. ISSN 0025-4363 is FatCat Studios published bimonthly by the Medical and Chirurgical Faculty of Maryland, 1211 Cathedral St., Baltimore, MD 21201, and is a membership benefit. Subscription rates: U S. and U S. possessions, one year: nonmembers $45; foreign $57. Single copy: members $5; nonmembers $7. Periodicals postage paid Advertising Representative at Baltimore, MD and at additional mailing offices. POSTMASTER: send address changes to Maryland Michelle Deiter Medical Journal. 1211 Cathedral St., Baltimore, MD 21201-5585. FAX 410-547-0915. MedChi, The Maryland State Medical Society 1211 Cathedral Street, Baltimore MD 21201 The views in this publication are those of the authors and do not necessarily reflect the opinion of the 410-539-0872; Toll Free 800-492-1056 Medical and Chirurgical Faculty of Maryland. Publishing an advertisement does not imply endorsement Fax: 410-547-0915 of any product or service offered, or approval of any representation made. www.medchi.org MMJ Vol 48 No 1 4 LETTERS TO THE EDITOR Was DiGeorge’s syndrome considered in the setting of conotruncal congential cardiac defects? I read with interest your article in the diac defects such as described in your Maryland Medical Journal entitled article, the diagnosis of DiGeorge’s syn¬ “A 66-year-old-woman with pneumo¬ drome comes to mind. Has this possibil¬ nia and right heart failure” [ 1998;47:177- ity been evaluated in the work up of this 181 ]. 1 noticed the differential WBC count patient? was remarkable for a lymphocyte count of 0, implying an equivalent CD4 count. Daniel Alexander, M.D. Dr. Alexander is from the department of While this finding would immediately internal medicine, Franklin Square suggest the possibility of HIV disease, in Hospital. ■ the setting of conotruncal congenital car¬ Patient did not share the associated facial dysmorphism associated with DiGeorge syndrome D r. Alexander has astutely com¬ the DiGeorge syndrome, and our patient mented on an association between did not share the associated facial lymphopenia and congenital dysmorphism described above, therefore conotruncal abnormalities, known as the making the DiGeorge syndrome less 1 ikely. DiGeorge syndrome. DiGeorge originally In addition, we are privy to one item that described infants with hypocalcemic sei¬ Dr. Alexander did not have access to - the zures, severe infections, and deficient cell rest of the patient’s hospital chart - which mediated immunity with the absence of the shows that lymphopenia was recorded only thymus and parathyroid glands. While there on the day of admission, and therefore may are wide variations in both the clinical and not truly be representative of the patient’s immunological manifestations, the immunological health. DiGeorge syndrome is also associated with We greatly appreciate Dr. Alexander’s cardiovascular abnormalities, including interesting comments. aortic interruption and truncus arteriosus, Nathan H. Carliner, M.D. as well as facial dysmorphism characterized R. Michael Benitez, M.D. by hypertelorism, micrognathia, a small “fish¬ Drs. Carliner and Benitez are with the like” mouth, a small philtrum, a malformed University of Maryland School of Medi¬ nose, bilateral cataracts, and a high arched, cine, division of cardiology. or cleft, palate.1 1. Perloff JK. The Clinical Recognition of Anomalies of pulmonary venous return Congenital Heart Disease, Fourth Edition. and atrial septal defects are not characteris¬ W.B. Saunders Company: Philadelphia, PA; tic cardiac malformations associated with 1994. ■ Maryland Medical Journal January/February 1999 5 MEDICINE MARYLAND in review Safuh Attar, M.D., John V. Conte, Jr., M.D., Stuart C. Ray, M.D., is one of the authors of a and Josephs. McLaughlin, M.D., published an report published in the January 1999 issue of the article entitled Primary Cardiac Tumors in The Journal of Virology revealing new gene varia¬ Journal of the Pennsylvania Association for tions of HIV. The report, a joint effort between Thoracic Surgery (1998 ;6:34-3 8). The authors scientists at Johns Hopkins and in India, shows review 38 patients with a rare diagnosis of that different forms of HIV in India seem to primary cardiac tumors. They find that while be combining. The authors conclude that malignant tumors have a very serious progno¬ this may be an indication that current ap¬ sis, excellent surgical results are seen with the proaches to vaccine development need to benign tumors. Drs. Attar, Conte, and be revisited. Dr. Ray, who directed the U.S. McLaughlin are from the University of Mary¬ arm of the study, is from the Johns Hopkins land School of Medicine and Medical Center. Medical Institutions. Hugh Calkins, M.D., is the lead author of a Stephen S. Gottlieb, M.D., is lead author of a study suggesting that radiofrequency catheter study finding that beta-blockers improve sur¬ ablation is safe and beneficial as a nonsurgical vival after a heart attack regardless of age or treatment for rapid heart rhythms in both chil¬ medical condition. The study, published Au¬ dren and adults. The study was published in gust 20, 1998, in the New England Journal of the January 19, 1999, issue of Circulation. Medicine, found that in over 200,000 patients Researchers looked at 1,050 patients over a beta blockers improved the two-year survival three-year period. Reviewing three types of by 42%. Authors conclude that their findings catheter ablations, authors report a high suc¬ should prompt physicians to prescribe beta cess level, low recurrence rate, and low rate of blockers on a routine basis for all patients who major complications. Dr. Calkins is director of have a heart attack. Dr. Gottlieb is director of electrophysiology at the Johns Hopkins Medi¬ the cardiac care unitatthe University ofMaryland cal Institutions. Medical Center. Austin Doyle, M.D., recently published an Michael Levine, M.D., and colleagues published article showcasing a discovery that may boost an article in the December 1998 issue of the the effectiveness of chemotherapy. The article Journal of Clinical Endocrinology and Me¬ was published in the December 22,1998, issue tabolism reporting on a new monitoring tech¬ of Proceedings of the National Academy of nique for thyroid cancer. Because current moni¬ Sciences. The researchers found “a cancer toring techniques have been found to cause resistance protein that rapidly pumps out che¬ anxiety and illness in patients as well as a slight motherapy from a certain line of breast cancer risk of accelerating tumor growth, a new method cells.” They call the newly discovered pump to detect left-over thyroid cells was sought. the Breast Cancer Resistance Protein. This Researchers discovered that a blood test can discovery may answer the problem of drug show, with an extreme level of sensitivity, circu¬ resistance, a major problem for many cancer lating thyroid cells. Dr. Levine is from the Johns patients. Dr. Doyle is associate professor of Hopkins Medical Institutions. Other Hopkins medicine at the University of Mary land School researchers were Matthew D. Ringel, M.D., and ofMedicine. Paul W. Ladenson, M.D. PHYSICIANS INTERESTED in being included in Maryland Medicine in Review should send a photocopy of their recently published articles (including journal citation) to: Maryland Medicine in Review, Maryland Medical Journal, 1211 Cathedral Street, Baltimore, MD 21201 MMJ Vol 48 No 1 6 Long-term functional results after manipulation of the frozen shoulder Jerome P. Reichmister, M.D., and Steven L. Friedman, M.D. ABSTRACT: The use of shoulder manipulation in the treat¬ ment of frozen shoulder syndrome remains controversial. Opponents cite the risk of dislocation, fracture, nerve palsy, Dr. Reichmister is chairman, depart¬ and rotator cuff tearing as limiting the usefulness ofmanipu¬ ment of orthopaedic surgery, Sinai lation. A retrospective study of 38 shoulder manipulations in Hospital, clinical associate professor, 32 patients was performed. These patients were followedfor orthopaedic surgery and medicine, an average time of 58 months. The patients were examined in University of Maryland, and clinical follow up for combined shoulder range of motion, external instructor, orthopaedic surgery, and internal rotation strength, and status of the long head of Johns Hopkins. Dr. Friedman is the biceps. Manipulation was performed in all patients by the director of hand surgery, Sinai senior author and supervised physical therapy was begun Hospital, and clinical instructor, within 24 hours of the manipulation. The average recovery division of orthopaedic surgery, time was 13 weeks. University of Maryland. In this series, 97% of patients had relief of pain and recovery of near complete range of motion, although 8% required a second manipulation to obtain a successful result. Mild weakness to manual muscle testing was present in 5.3% of patients in external rotation and 10.5% of patients in internal rotation. There was no deterioration of shoulder function with time. In fact, most patients improved with passage of time, even more. There was no evidence of biceps tendon rupture or rotator cuff insufficiency at the time of follow up in any of the patients. No fractures, dislocations or nerve palsies were observed, although one patient who had no premanipulation arthrogram was found to have a rotator cuff tear a few months after failed manipulation. Manipula¬ tion of the shoulder can therefore be offered to reduce the pain and period of disability in patients who fail conservative Reprints: J.P. Reichmister, M.D., 6080 Falls Rd., Baltimore, Maryland 21209. treatment of frozen shoulder syndrome. Maryland Medical Journal January/February 1999 7 Frozen shoulder describes a tients were examined in follow¬ Table 1 Associated illnesses up for combined shoulder range clinical syndrome characterized by disabling shoulder pain, Number of patients Percent of motion, external and internal often worse at night, and limi¬ DJDCervical 13 41 rotation muscle strength, and evi¬ tation of motion. Despite Lumbar 3 9.5 dence of rupture of the long head several valuable investiga¬ Cardiac Disease 7 22.5 of the biceps. tions into the nature of this syn¬ Diabetes 2 6 Twenty-six patients (81 %) had Thyroid Disease 2 6 associated illnesses (Table 1). drome, its etiology remains Hydradenitis 1 3 Cervical spine disease was unknown8’9,10,11’12'20’23'29,30 and Recent Trauma 2 6 present in 13 patients. Diabetes its treatment controver¬ Rheumatoid Arthritis 1 3 mellitus was present in two pa¬ sial.4,5,10,18,21,29 Treatment options Other 1 3 tients, cardiac disease in seven include observation alone,2,5 The incidence of associated illnesses in the study group is physical therapy,2,4,5,32,33 oral4 or shown. These should be considered by the treating physician patients, thyroid disease in two when evaluating shoulder pain. locally injected5 corticosteroids, patients, and a history of recent mu closed manipulation,1317 stellate minor trauma was present in two ganglion block,22 arthroscopy,26,28,34 brisement, and arthro- patients. One patient had undergone resection for an axillary tomy with release of contracted structures under direct hidradenitis of the ipsilateral extremity seven months before visualization.8,10,18,21,29 Recently, others have talked about presentation. arthroscopic release of contracted structures.34 35 Perhaps the Treatment before manipulation included supervised physi¬ most controversial treatment is closed manipulation.18 cal therapy, non-steroidal anti-inflammatory agents, and There are currently no controlled prospective studies corticosteroid injections of the involved shoulder. The documenting the efficacy of manipulation of the shoulder in average duration of physical therapy before manipulation treating this disorder. Several retrospective reviews, how¬ was 12 weeks, although several patients had previous ever, suggest that the duration of symptoms may be reduced regimens of variable duration prior to the initial consulta¬ by this treatment.13'17 The opponents of manipulation sug¬ tion. The distribution of conservative therapies is docu¬ gest that the risks of rotator cuff tear, humeral fracture, mented in Table 2. shoulder dislocation, and nerve palsy, limit its usefulness in Patients were considered candidates for manipulation if this disorder.10,18,21 A retrospective analysis was undertaken their symptoms failed to respond to conservative therapy as to evaluate the role of manipulation in the treatment of frozen shown in Table 2. In addition to severe restriction of motion, shoulder syndrome in terms of pain relief, return of motion, moderate restriction of motion associated with severe pain complications and long-term function. was considered an indication for manipulation. Manipulation was performed under general anesthesia Materials and methods with total relaxation (paralysis) in all patients. The lever arm on the proximal humerus was minimized to prevent Thirty-eight shoulders in 32 patients were evaluated in this study. The diagnosis of frozen shoulder syndrome was humeral fracture. Internal rotation was performed first made in all patients based on the presence of severe shoulder followed by external rotation. Careful abduction and pain and limitation of motion. Arthrography was performed finally forward flexion were then performed. Adduction on nine shoulders in nine patients. was last performed to break All arthrograms confirmed the Table 2. Conservative treatment down posterior joint capsule ad¬ diagnosis by demonstrating re¬ Number of shoulders Percent hesions. All motions were re¬ duced volume within the capsule. Physical Therapy 36 95 peated until maximum motion The medical records of all Non-steroidal anti- was obtained. After manipula¬ patients were reviewed with inflammatory drugs 29 76 tion, interarticular injection of particular attention to age, sex, Injections One 19 50 steroid (decadron 4 mg) and lo¬ arm dominance, duration of Two 2 5 cal anesthetic (lidocaine 1%) symptoms, range of motion, as¬ Three 2 5 was performed. An aggressive sociated illness, and contralat¬ The distribution of patients undergoing conservative supervised physical therapy regi¬ treatment is shown. eral shoulder symptoms. All pa¬ ment was initiated within 24 hours 8 MMJ Vol 48 No 1