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Insomnia is a common complaint with potentially significant medical and psychologic complications. In some cases insomnia presents as a symptom of another underlying medical, psychiatric or environmental condition. In these cases, management of insomnia depends on accurate diagnosis and successful treatment of the underlying condition. In other cases, insomnia is a primary disorder requiring direct treatment. Pharmacologic treatments include nonprescription medications, sedating tricyclic antidepressants, benzodiazepines and related drugs. Behavior management methods that may be administered in the office setting include stimulus control therapy, sleep restriction therapy and sleep hygiene education. Although prescription medications and behavior therapy have similar short-term efficacy, behavior interventions are recommended as the first line of treatment for primary insomnia because of their greater safety and long-term efficacy.

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Obsessive-compulsive disorder is relatively common; however, its actual incidence has only recently become clear. The neurotransmitter serotonin appears to have a central role in this disorder. Males and females are affected equally, with onset usually occurring in late adolescence. Symptoms include intrusive thoughts that lead the patient to perform repetitive rituals that interfere with daily living. Although patients are typically distressed by these thoughts and rituals, they seldom volunteer their symptoms. Successful diagnosis often requires specific questioning by the physician. Treatment is directed at symptom reduction; however, complete remission of symptoms is unusual. Pharmacologic therapy usually includes clomipramine or antidepressant treatment with selective serotonin reuptake inhibitors, but in dosage ranges higher than those typically used in the treatment of depression. Behavior therapy has also been proved effective, both alone and in conjunction with pharmacologic therapy.

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Neutropenia is an uncommon but potentially serious complication of drug therapy. Many drugs, especially antibiotics, can produce this untoward effect. Typically, drug-induced neutropenia occurs in a patient receiving a semisynthetic penicillin for two weeks or more. The cause is believed to be either a hypersensitivity reaction or a toxic dose-related suppression of white blood cell precursors. Most patients improve after discontinuation of the drug.

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Pulmonary disease can impair sexual functioning. The medications used to alleviate the disease can both help and hinder sexual functioning; some patients may have greater disability from the psychological sequelae. Younger patients (those with asthma or cystic fibrosis) tend to have intermittent flareups and can usually function fairly well sexually between bouts. Older patients with chronic obstructive pulmonary disease tend to have a more prolonged course; they are also more prone to concomitant disease that can interfere with sexual functioning. Through careful and concerned questioning, the physician can do much to help both of these groups to better sexual functioning.

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The purpose of this study was to elicit the circumstances of occurrence and organism sensitivities of Klebsiella pneumoniae bacteremia in the community hospital, since data on this illness from the community hospital are rare. All records of documented Klebsiella pneumoniae bacteremia (46 cases) at Alachua General Hospital, Gainesville, Florida, over the period July 14, 1982, through July 27, 1985, were reviewed in detail. Fifty-nine percent (27 organisms) were nosocomial, whereas 41% (19 organisms) were community acquired. The most common predisposing disorders in these patients were, in decreasing order, malignancy; following gastrointestinal or biliary surgery; biliary tract obstruction; diabetes; and unknown. Twenty-two percent (10) of the patients died from bacteremia. The majority of organisms tested were sensitive to mezlocillin, cephalothin, cefoxitin, tetracycline, tobramycin, gentamicin, co-trimoxazole and ceftizoxime. Therapy was considered to be appropriate in 89% (41) of the patients and inappropriate in 10.9% (5) of the patients. Contrary to previous thought, Klebsiella pneumoniae bacteremia is a relatively common problem in the community hospital and may be community acquired as well as nosocomial. There are many characteristics of this disease in the community that are different from those reported in studies on Klebsiella pneumoniae bacteremia from large referral centers.

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Sexuality is often overlooked in rehabilitation of the handicapped. These patients need a family physician who can offer constructive help without being embarrassed or awkward. Awareness that sexuality encompasses more than physical attractiveness and penile-vaginal intercourse, use of sexual imagery and concentration on body areas that retain sensation are essential in the sexual rehabilitation of handicapped patients. Rehabilitation is more likely to succeed when the patient has a supportive sexual partner.

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The need for sexual expression continues until death. Older patients have been erroneously denied these feelings by an uninformed society. As a result, older individuals either cease to function sexually or else continue to remain active with much needless guilt. The informed and caring physician can do much to alleviate this unnecessary suffering. Education of both patients and society is needed. The normal physiologic changes that occur need to be explained, as does the possibility of alternate means of sexual expression. Of course, the moral views of the patient must be considered. If the physician is not comfortable discussing problems related to sexuality, then he must be willing to refer the patient/couple to someone who is.

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The construction and validation of a computerized device to test simple reaction time and decision-making time is discussed. The device is required to demonstrate repeatability (consistency of response times from human subjects) across replications of the same experimental condition. A second requirement of the device is that it must separately and independently measure simple reaction time and the time it takes to process one bit of information. The concepts behind the construction of the box are discussed, as well as the design of its internal circuits to achieve these specifications.

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The sexual concerns of patients with cancer may be overlooked during the acute stage of illness. Both the general stress of hospitalization and the specific threat of surgery can affect sexuality. Breast cancer and cancer of the reproductive organs cause the most concern, although other tumors can be as devastating. "Ostomies" and limb amputations raise special questions, and radiation therapy affects sexual and reproductive function. Underlying depression has a profound effect.

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While pregnancy is a major event in most couples' lives, there are no predictable changes in sexuality. Fears of damaging the fetus are unwarranted, even during the last weeks of pregnancy, provided there are no complications. Meticulous episiotomy technique can lessen the healing time and allow the couple to resume mutually satisfying intercourse sooner.

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Sexual functioning after myocardial infarction is a primary concern for patients, yet many physicians fail to discuss this part of rehabilitation. Even with instructions, more than one-fourth of previously active patients fail to resume intercourse after a coronary event. Patients with a healthy sexual relationship before the infarction have a much better chance for full recovery of sexual activity.

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As the aged segment of the nation's population continues to increase, physicians must be aware of older individuals' sexual problems. Most of these people remain interested in and capable of sexual enjoyment. Older patients should be informed of the physiologic changes that accompany aging and should be assured that these changes, though they may change sexual style, need not detract from sexual enjoyment. The widow's/widower's syndrome must be recognized if it is to be managed successfully.

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