- Email: [email protected]
Hypertensive crises: The need for urgent management
CURRENT LITERATURE
incuffiency. Mean perioperative(stress)urinary cortisol levels(321 t 63 /lg per 24 hours)werenot significantly different from postoperative(nonstress)cortisol levels (averaging 247 2 89 pg) and all values were within a normal range. All but one patient had normal endogenousadrenocortical function and appropriatebiochemicalresponsesto stress. The authorsconcludedthat becausepatientsmountednormal responses to stresswithout supplementaladministrationof steroids,supplementaldosesmay be unnecessaryfor major operativeprocedures.Theseresultsdo not showthe absence of hypothalamic-pituitaty-adrenal axis suppression.That very likely exists.However, the resultsdo suggestthe clinical and biochemicalramificationsof such suppressionare negligible.-F.P. IUORNO,JR. Reprint requests to Dr Friedman: Department of Orthopaedic Surgery, Medical University of South Carolina, 171 Ashley Ave, Charleston, SC 29425.
The Polymorphous Odontogenic Cyst. High AS, Main DMG, Khoo SP,et al. J Oral Patbol Med 25:25, 1996 The purposesof this study wereto showreportsof unusual cystic lesionsthat arenot readily classifiedasregularodontogeniecysts, to proposethe term polymorphousodontogenic cyst for their classification,and to alert clinicians to some of their commoncharacteristics.These lesionshave been diagnosedas median-mandibular,glandular, sialo-odontogenie,and botryoid odontogeniccysts.Someof the common characteristicsinclude the following: 1) odontogenicand glandularcomponentsto the histology, 2) extensivemultilocular character, 3) root displacementand loss of tooth vitality, 4) noncornifiedepitheliallining, and5) a 30%recurrencerate. The authorsbelieve that cysts with thesecharacteristics can be excluded from ordinary odontogeniccysts and shouldfall into their own classificationof polymorphous odontogeniccysts.- W. CARVAJAL Reprint requests to Dr High: Division of Dental Surgery, Leeds Dental Institute, Leeds, United Kingdom.
Alpha Hydroxy Acids in Skin Care. Clark CP. Clin Plast Surg 23:49, 1996 Alpha hydroxy acids (AHAs) act on the epidermisby causingdesquamation,plasticization,and promotionof normal epidermaldifferentiation. The commonstructureof all AHAs is a terminalcarboxyl groupwith oneor two hydroxyl groups on the secondalpha carbon and a variable-length carbonchain. They have beenusedsuccessfullyfor the treatment of xerosis,ichthyosis,solarlentigos,actinic keratoses, warts, melasma,acne,and photoaging.AHAs diminishcorneocyte cohesionand keratinocyte plugging in acne.AHAs reducerhytids in aging skin by increasingepidermalthickness,with more orderly differentiation, enhancedrete ridge pattern, and dispersal of melanin at the basal layer. To deter-
mine the appropriateAHA strategy, a history and physical examinationshouldbe performed.Relevant factors include the following: prior radiation, prior cosmeticsurgery,prior peelsandresults,pregnancy,medications,history of herpes simplex,history of hypertrophic scarring,presentsunexposure, Fitzpatrick skin type, degreeof actinic damage,and associatedpathology. Patient education is important in achievingthe desiredresult. Many products,regimines,and adjunctsareavailable. Complicationsof AHAs are minimal but include prolonged erythema, hyperpigmentation,and herpetic eruption.-R.H. HAUG Reprint requests to Dr Clark Center for Plastic and Reconstructive Surgery, 2.501 North Orange Ave, Suite 310, Orlando, FL 32804.
1039 Comparison of Computed Tomography Imaging Before and After Functional Treatment of Bilateral Condylar Fractures in Adults. Choi BH. Int J Oral Maxillofac Surg 25:30, 1996 There have beenfew studiesshowingany correlationbetween the anatomicrestitution of the condyle and the function of the temporomandibularjoint in adult patients with conservatively treated condylar fractures. A 1989 article showedno correlationbetweenthe morphologicalrestitution and the function of the temporomandibular joint, and most of thepatientshadunilateralfractures.A 1990articledemonstratedby computedtomography(CT) imagingthat the correlation was detectableonly in casesof severely limited function. In a 1993 study it was concludedthat the degree of realignmentof the condyule was related to the function of thejoint. There areno publishedreportson the correlation in adult patientswith bilateral condylar fractures that are treated nonsurgically.In this investigation, 10 consecutive adult, male patients(averageage of 30 years) were treated with a nonsurgicalprotocol andevaluatedwith CT imaging. PretreatmentCT imageswere availablewithin 7 days after trauma; 7 of the patients also had mandibularsymphysis fractures,which weretreatedwith miniplating.Treatmentof the bilateral condylar fractures consistedof intermaxillary fixation with elasticsfor 10 days followed by mandibular manipulation(manualguiding of the jaw movement in a desirablepattern weekly for 4 weeks),and active jaw exercises.Patientswere thenfollowed monthly for 6 monthsand underwent
follow-up
CT imaging
at 6 months. The initial
anterior open bite was eliminated in all patients, and the occlusionwasnormal within 3 monthsafter treatment.The mouth could be opened to more than 50 mm and lateral excursions were within normal limits. The post-treatment
CT imagesshowedthat bony consolidationbetweenthe condyle and the ramushad taken placein all cases.There was no resorptionof the fracturedcondyle or changein the contour of the glenoid fossa or the articular eminence. No patient
had any clinical symptomsof derangementsuchasclicking or crepitation.The authorconcludesthat re-establishment of occlusion and function occurs as a result of adaptationof the masticatorymuscles.-R.E. ALEXANDER Reprint requests to Dr Choi: Department of Oral and Maxillofacial Surgery, Wonju Christian Hospital, Yonsei University, 162 IlsanDong, Wonju Kaugwon-Do, South Korea.
Hypertensive Crises: The Needfor Urgent Management. Varon J, Fromm RE. PostgradMed 99:189, 1996 An estimated60 million Americans have hypertension. Hypertensivecrisesarerelatively uncommon,but whenthey do occur they are often life-threatening and demandearly recognition andmanagement.Most patientsare undertreatmentfor essentialhypertensionandwithdrawalfrom an antihypertensivedrug is the mostcommoncauseof acuteblood pressureelevation.The authorsdefineseveraltermsthat are often usedinterchangably.Hypertensivecrisesare situations resulting from elevatedblood pressurethat are potentially life- or organ-threatening.Hypertensive emergenciesare clinical situationswherethe blood pressuremustbe lowered within anhour to avoid seriousend-organdamage.Hypertensive urgenciesare elevationsof blood pressurethat can be treated with antihypertensiveagentsto reducethe pressure within 24 hours.Malignant hypertensionis a syndromecharacterized by elevated blood pressureaccompaniedby encephalopathyor nephropathy,or by papilledemaand/or hemolytic anemia.This article addresses the first conditionhypertensive crises.It is not defined by a specific blood pressure level but organ damage that is associated with acute
1040
CURRENT
elevations of the blood pressure. Common causes are acute glomerulonephritis, collagen vascular disesases, drug abuse, head trauma, preeclampsia and eclampsia, and so on. Both cerebral and coronary hypoperfusion must be avoided when managing the crises. The article then discusses, in-depth, the short-acting parenteral agents commonly used to manage the crises, including sodium nitroprusside, calcium channel blockers (nifedipine, nicardipine), adrenergic blocking agents (Esmolol, Labetalol, Phentolamine), Timethaphan Camsylate, Diazoxide, Clonidine, Angiotensin-Converting Enzyme Inhibitors, nitroglycerin, and other agents. They discuss the favorable actions as well as therapeutic drawbacks and precautions of each agent. For example, the authors favor nicardipine over nifedipine and they warn of problems associated with the administration of sodium nitroprusside.-R.E. ALEXANDER ReprintRequest to Dr Varon:Anderson CancerCenter,Department of Anesthesiologyand Critical Care, 1515 HolcombeBlvd, AC1.171,
Houston,
TX 77030.
AddressingDifficult Areas in Body Contouring With Emphasison CombinedTumescentand Syringe Techniques. HunstadJP. Clin Plast Surg 2357, 1996 Liposuctionhasbecomea well-acceptedprocedurefor the removalof localizedareasof fat. It is oneof the mostpopular estheticproceduresin the United Statesbecauseof its proven safety andefficacy. The tumescenttechniqueis a methodof large-volumedilute lidocainewith epinephrinesubcutaneous infiltration. It expandsand magnifiesthe deformity to be treated,minimizesbleedingassociatedwith liposuctionand may allow liposuction and other surgicalproceduresto be performedwithout generalanesthesia. The syringetechnique minimizesbleeding,increases precisionandenhancesresults with liposculpture.The syringe techniqueis silent, easy to use, simple,light weight, and reducesoperatorfatigue. It is more precise,lesstraumatic, and without tubing resistance. It is a closedsystemand no aerosolis produced.The dilute lidocaine with epinephrinesolution is delivered under high pressureover 15to 20 minutesuntil the tissuesbecomehard, and the “fountain sign” is noticed. A blunt tip createsa pretunnel. The syringe is then introduced and evacuated. Preoperativeassessment with markingwill enhanceaccuracy of fat removal. The time for anesthesia may be long because the lidocaine solution is dilute. The epinephrine is 1:1,000,000.Removal of localized facial adiposity is easily achievedwith thesetechniques.Canulasof 1.5-3.0mm are suggestedfor the face. A featheringtechniqueis mosteffective. Entry pointsinclude the oral commissure,posteriorear lobe,intranasal(vestibular)area,androot of the helix. When addressingthe neck, 200 to 500 mL are routinely infused andthen 10 to 15minutesareallowedto pass.The technique is similarto that for the face. Ten to 50 mL of fat removal is consistant.It is important to slightly undercorrectthe deformity, becausepostoperativeresorbtionof fluids and cells will occur during the healingprocess.The arms,thighs,abdomen, and legs may also be addressedwith thesetechniques-R.H. HAUG Reprint requests to Dr Hunstad: Plastic Surgery, 8736 University
The Hunstad Center City Blvd, Charlotte,
for Cosmetic NC 28213.
Factors Influencing the Patterns of Invasion of the Man-
LITERATURE
dible by Oral Squamous Cell Carcinoma. Brown JS, Browne RM. Int J Oral Maxillofac Surg 24:417, 1995 Knowledgeof the path of entry andinvasionof mandibular tumors and patternsof intraboney spreadis essentialto the developmentof logical approachesto mandibularresections for cancer. Two patters of squamouscell carcinoma invasionaregenerallyacknowledged.In the invasivepattern, fingersandislandsof tumor advanceindependentlyinto cancellous spaces,with no intervening layer of connectivetissue.In the erosivepattern, the tumor advanceson a broad front with a connective-tissuelayer and active osteoclasts separatingthe bonefrom the tumor. In this study, the mandibles from 33 patientswho required mandibularrim resections were microscopicallystudiedafter removal and comparedwith the preoperativeradiographs.Evidence gathered in this study suggeststhat the erosive pattern develops through a mixed patternto the invasive pattern asthe tumor progressesthrough bone. The invasive pattern was evident at a much shallowerdepth in the posteriormandiblethan in the premolarand symphysisregions.The authorshypothesize that the more superficialalveolarbone respondsby resorbingin advanceof the tumor, but the basalboneis unable to respondin the sameway andbecomeswidely infiltrated. Although the periodontalmembranehas long been conjectured to be the entry pathway to the mandible,evidenceis lacking. The attachedmucosa,with its firm collagenattachment to bone, is proposedby these authors as the main route of tumor entry into the mandiblein both dentulousand edentulousmandibles.-R.E. ALEXANDER Reprint Requests Hospitals Trust, United Kingdom.
to Dr Brown: Regional Maxillofacial Unit, Aintree Walton Hospital, Rice Lane, Liverpool L91AE,
Anorexia Nervosa and Bulimia Nervosa: When the Pursuit of Bodily ‘Perfection’ Becomesa Killer. Zerbe KJ. PostgradMed 99:161, 1996 The incidencesof anorexia nervosaand bulimia nervosa are on the rise in Westernsocietiesand now affect an estimated 1.2 million young womenin the U.S. The morbidity and mortality ratesare impressive.Anorexia, alone,hasan 18% to 20% mortality rate over time. The deathrate from bulimia may be equally high, but long-termstudiesarejust now being carried out. No single causefor either disease has been found. The diseasesresult from an amalgamof emotional,physical, sociologic,and family factors, and recent studiessuggestthere may alsobe an inheriteddisposition. The stereotypical“driven woman” conceptis no longer valid. Infants and childrencan have a problem,ascan males. A significantnumberof afflicted patientshave a pasthistory of physical or sexual abuse.The diseasesmay manifestin athletic womenwho keeptraining despiteinjuriesor in older women who are trying to maintain their youthful figures. Most are too obsessed with their appearance(asthey seeit) to be concernedaboutthe medicaldamagebeing done.This article discusses the behavioralcluesto eatingdisorders,and the role of the primary care physician in intervention. The diseases canaffect all of thebody systemsandcausemultiple medicalproblems,but more than anything the patientsneed psychotherapy.-R.E. ALEXANDER Reprint Requests KS 66601.0829.
to Dr Zerbe:
Menninger
Clinic,
Box 829, Topeka,
incuffiency. Mean perioperative(stress)urinary cortisol levels(321 t 63 /lg per 24 hours)werenot significantly different from postoperative(nonstress)cortisol levels (averaging 247 2 89 pg) and all values were within a normal range. All but one patient had normal endogenousadrenocortical function and appropriatebiochemicalresponsesto stress. The authorsconcludedthat becausepatientsmountednormal responses to stresswithout supplementaladministrationof steroids,supplementaldosesmay be unnecessaryfor major operativeprocedures.Theseresultsdo not showthe absence of hypothalamic-pituitaty-adrenal axis suppression.That very likely exists.However, the resultsdo suggestthe clinical and biochemicalramificationsof such suppressionare negligible.-F.P. IUORNO,JR. Reprint requests to Dr Friedman: Department of Orthopaedic Surgery, Medical University of South Carolina, 171 Ashley Ave, Charleston, SC 29425.
The Polymorphous Odontogenic Cyst. High AS, Main DMG, Khoo SP,et al. J Oral Patbol Med 25:25, 1996 The purposesof this study wereto showreportsof unusual cystic lesionsthat arenot readily classifiedasregularodontogeniecysts, to proposethe term polymorphousodontogenic cyst for their classification,and to alert clinicians to some of their commoncharacteristics.These lesionshave been diagnosedas median-mandibular,glandular, sialo-odontogenie,and botryoid odontogeniccysts.Someof the common characteristicsinclude the following: 1) odontogenicand glandularcomponentsto the histology, 2) extensivemultilocular character, 3) root displacementand loss of tooth vitality, 4) noncornifiedepitheliallining, and5) a 30%recurrencerate. The authorsbelieve that cysts with thesecharacteristics can be excluded from ordinary odontogeniccysts and shouldfall into their own classificationof polymorphous odontogeniccysts.- W. CARVAJAL Reprint requests to Dr High: Division of Dental Surgery, Leeds Dental Institute, Leeds, United Kingdom.
Alpha Hydroxy Acids in Skin Care. Clark CP. Clin Plast Surg 23:49, 1996 Alpha hydroxy acids (AHAs) act on the epidermisby causingdesquamation,plasticization,and promotionof normal epidermaldifferentiation. The commonstructureof all AHAs is a terminalcarboxyl groupwith oneor two hydroxyl groups on the secondalpha carbon and a variable-length carbonchain. They have beenusedsuccessfullyfor the treatment of xerosis,ichthyosis,solarlentigos,actinic keratoses, warts, melasma,acne,and photoaging.AHAs diminishcorneocyte cohesionand keratinocyte plugging in acne.AHAs reducerhytids in aging skin by increasingepidermalthickness,with more orderly differentiation, enhancedrete ridge pattern, and dispersal of melanin at the basal layer. To deter-
mine the appropriateAHA strategy, a history and physical examinationshouldbe performed.Relevant factors include the following: prior radiation, prior cosmeticsurgery,prior peelsandresults,pregnancy,medications,history of herpes simplex,history of hypertrophic scarring,presentsunexposure, Fitzpatrick skin type, degreeof actinic damage,and associatedpathology. Patient education is important in achievingthe desiredresult. Many products,regimines,and adjunctsareavailable. Complicationsof AHAs are minimal but include prolonged erythema, hyperpigmentation,and herpetic eruption.-R.H. HAUG Reprint requests to Dr Clark Center for Plastic and Reconstructive Surgery, 2.501 North Orange Ave, Suite 310, Orlando, FL 32804.
1039 Comparison of Computed Tomography Imaging Before and After Functional Treatment of Bilateral Condylar Fractures in Adults. Choi BH. Int J Oral Maxillofac Surg 25:30, 1996 There have beenfew studiesshowingany correlationbetween the anatomicrestitution of the condyle and the function of the temporomandibularjoint in adult patients with conservatively treated condylar fractures. A 1989 article showedno correlationbetweenthe morphologicalrestitution and the function of the temporomandibular joint, and most of thepatientshadunilateralfractures.A 1990articledemonstratedby computedtomography(CT) imagingthat the correlation was detectableonly in casesof severely limited function. In a 1993 study it was concludedthat the degree of realignmentof the condyule was related to the function of thejoint. There areno publishedreportson the correlation in adult patientswith bilateral condylar fractures that are treated nonsurgically.In this investigation, 10 consecutive adult, male patients(averageage of 30 years) were treated with a nonsurgicalprotocol andevaluatedwith CT imaging. PretreatmentCT imageswere availablewithin 7 days after trauma; 7 of the patients also had mandibularsymphysis fractures,which weretreatedwith miniplating.Treatmentof the bilateral condylar fractures consistedof intermaxillary fixation with elasticsfor 10 days followed by mandibular manipulation(manualguiding of the jaw movement in a desirablepattern weekly for 4 weeks),and active jaw exercises.Patientswere thenfollowed monthly for 6 monthsand underwent
follow-up
CT imaging
at 6 months. The initial
anterior open bite was eliminated in all patients, and the occlusionwasnormal within 3 monthsafter treatment.The mouth could be opened to more than 50 mm and lateral excursions were within normal limits. The post-treatment
CT imagesshowedthat bony consolidationbetweenthe condyle and the ramushad taken placein all cases.There was no resorptionof the fracturedcondyle or changein the contour of the glenoid fossa or the articular eminence. No patient
had any clinical symptomsof derangementsuchasclicking or crepitation.The authorconcludesthat re-establishment of occlusion and function occurs as a result of adaptationof the masticatorymuscles.-R.E. ALEXANDER Reprint requests to Dr Choi: Department of Oral and Maxillofacial Surgery, Wonju Christian Hospital, Yonsei University, 162 IlsanDong, Wonju Kaugwon-Do, South Korea.
Hypertensive Crises: The Needfor Urgent Management. Varon J, Fromm RE. PostgradMed 99:189, 1996 An estimated60 million Americans have hypertension. Hypertensivecrisesarerelatively uncommon,but whenthey do occur they are often life-threatening and demandearly recognition andmanagement.Most patientsare undertreatmentfor essentialhypertensionandwithdrawalfrom an antihypertensivedrug is the mostcommoncauseof acuteblood pressureelevation.The authorsdefineseveraltermsthat are often usedinterchangably.Hypertensivecrisesare situations resulting from elevatedblood pressurethat are potentially life- or organ-threatening.Hypertensive emergenciesare clinical situationswherethe blood pressuremustbe lowered within anhour to avoid seriousend-organdamage.Hypertensive urgenciesare elevationsof blood pressurethat can be treated with antihypertensiveagentsto reducethe pressure within 24 hours.Malignant hypertensionis a syndromecharacterized by elevated blood pressureaccompaniedby encephalopathyor nephropathy,or by papilledemaand/or hemolytic anemia.This article addresses the first conditionhypertensive crises.It is not defined by a specific blood pressure level but organ damage that is associated with acute
1040
CURRENT
elevations of the blood pressure. Common causes are acute glomerulonephritis, collagen vascular disesases, drug abuse, head trauma, preeclampsia and eclampsia, and so on. Both cerebral and coronary hypoperfusion must be avoided when managing the crises. The article then discusses, in-depth, the short-acting parenteral agents commonly used to manage the crises, including sodium nitroprusside, calcium channel blockers (nifedipine, nicardipine), adrenergic blocking agents (Esmolol, Labetalol, Phentolamine), Timethaphan Camsylate, Diazoxide, Clonidine, Angiotensin-Converting Enzyme Inhibitors, nitroglycerin, and other agents. They discuss the favorable actions as well as therapeutic drawbacks and precautions of each agent. For example, the authors favor nicardipine over nifedipine and they warn of problems associated with the administration of sodium nitroprusside.-R.E. ALEXANDER ReprintRequest to Dr Varon:Anderson CancerCenter,Department of Anesthesiologyand Critical Care, 1515 HolcombeBlvd, AC1.171,
Houston,
TX 77030.
AddressingDifficult Areas in Body Contouring With Emphasison CombinedTumescentand Syringe Techniques. HunstadJP. Clin Plast Surg 2357, 1996 Liposuctionhasbecomea well-acceptedprocedurefor the removalof localizedareasof fat. It is oneof the mostpopular estheticproceduresin the United Statesbecauseof its proven safety andefficacy. The tumescenttechniqueis a methodof large-volumedilute lidocainewith epinephrinesubcutaneous infiltration. It expandsand magnifiesthe deformity to be treated,minimizesbleedingassociatedwith liposuctionand may allow liposuction and other surgicalproceduresto be performedwithout generalanesthesia. The syringetechnique minimizesbleeding,increases precisionandenhancesresults with liposculpture.The syringe techniqueis silent, easy to use, simple,light weight, and reducesoperatorfatigue. It is more precise,lesstraumatic, and without tubing resistance. It is a closedsystemand no aerosolis produced.The dilute lidocaine with epinephrinesolution is delivered under high pressureover 15to 20 minutesuntil the tissuesbecomehard, and the “fountain sign” is noticed. A blunt tip createsa pretunnel. The syringe is then introduced and evacuated. Preoperativeassessment with markingwill enhanceaccuracy of fat removal. The time for anesthesia may be long because the lidocaine solution is dilute. The epinephrine is 1:1,000,000.Removal of localized facial adiposity is easily achievedwith thesetechniques.Canulasof 1.5-3.0mm are suggestedfor the face. A featheringtechniqueis mosteffective. Entry pointsinclude the oral commissure,posteriorear lobe,intranasal(vestibular)area,androot of the helix. When addressingthe neck, 200 to 500 mL are routinely infused andthen 10 to 15minutesareallowedto pass.The technique is similarto that for the face. Ten to 50 mL of fat removal is consistant.It is important to slightly undercorrectthe deformity, becausepostoperativeresorbtionof fluids and cells will occur during the healingprocess.The arms,thighs,abdomen, and legs may also be addressedwith thesetechniques-R.H. HAUG Reprint requests to Dr Hunstad: Plastic Surgery, 8736 University
The Hunstad Center City Blvd, Charlotte,
for Cosmetic NC 28213.
Factors Influencing the Patterns of Invasion of the Man-
LITERATURE
dible by Oral Squamous Cell Carcinoma. Brown JS, Browne RM. Int J Oral Maxillofac Surg 24:417, 1995 Knowledgeof the path of entry andinvasionof mandibular tumors and patternsof intraboney spreadis essentialto the developmentof logical approachesto mandibularresections for cancer. Two patters of squamouscell carcinoma invasionaregenerallyacknowledged.In the invasivepattern, fingersandislandsof tumor advanceindependentlyinto cancellous spaces,with no intervening layer of connectivetissue.In the erosivepattern, the tumor advanceson a broad front with a connective-tissuelayer and active osteoclasts separatingthe bonefrom the tumor. In this study, the mandibles from 33 patientswho required mandibularrim resections were microscopicallystudiedafter removal and comparedwith the preoperativeradiographs.Evidence gathered in this study suggeststhat the erosive pattern develops through a mixed patternto the invasive pattern asthe tumor progressesthrough bone. The invasive pattern was evident at a much shallowerdepth in the posteriormandiblethan in the premolarand symphysisregions.The authorshypothesize that the more superficialalveolarbone respondsby resorbingin advanceof the tumor, but the basalboneis unable to respondin the sameway andbecomeswidely infiltrated. Although the periodontalmembranehas long been conjectured to be the entry pathway to the mandible,evidenceis lacking. The attachedmucosa,with its firm collagenattachment to bone, is proposedby these authors as the main route of tumor entry into the mandiblein both dentulousand edentulousmandibles.-R.E. ALEXANDER Reprint Requests Hospitals Trust, United Kingdom.
to Dr Brown: Regional Maxillofacial Unit, Aintree Walton Hospital, Rice Lane, Liverpool L91AE,
Anorexia Nervosa and Bulimia Nervosa: When the Pursuit of Bodily ‘Perfection’ Becomesa Killer. Zerbe KJ. PostgradMed 99:161, 1996 The incidencesof anorexia nervosaand bulimia nervosa are on the rise in Westernsocietiesand now affect an estimated 1.2 million young womenin the U.S. The morbidity and mortality ratesare impressive.Anorexia, alone,hasan 18% to 20% mortality rate over time. The deathrate from bulimia may be equally high, but long-termstudiesarejust now being carried out. No single causefor either disease has been found. The diseasesresult from an amalgamof emotional,physical, sociologic,and family factors, and recent studiessuggestthere may alsobe an inheriteddisposition. The stereotypical“driven woman” conceptis no longer valid. Infants and childrencan have a problem,ascan males. A significantnumberof afflicted patientshave a pasthistory of physical or sexual abuse.The diseasesmay manifestin athletic womenwho keeptraining despiteinjuriesor in older women who are trying to maintain their youthful figures. Most are too obsessed with their appearance(asthey seeit) to be concernedaboutthe medicaldamagebeing done.This article discusses the behavioralcluesto eatingdisorders,and the role of the primary care physician in intervention. The diseases canaffect all of thebody systemsandcausemultiple medicalproblems,but more than anything the patientsneed psychotherapy.-R.E. ALEXANDER Reprint Requests KS 66601.0829.
to Dr Zerbe:
Menninger
Clinic,
Box 829, Topeka,