Showing papers in "Annals of Internal Medicine in 1984"
TL;DR: To characterize the role of cardiac function in septic shock, serial radionuclide cineangiographic and hemodynamic evaluations were done on 20 patients with documented septicShock, finding that nonsurvivors had normal initial ejection fractions and ventricular volumes that did not change during serial studies.
Abstract: To characterize the role of cardiac function in septic shock, serial radionuclide cineangiographic and hemodynamic evaluations were done on 20 patients with documented septic shock. Although all patients had a normal or elevated cardiac index, 10 patients had moderate to severe depression of their ejection fraction with values below 0.40. Thirteen of twenty patients survived their episode. Paradoxically, 10 of 13 survivors, but none of the 7 nonsurvivors, had an initial ejection fraction less than 0.40 (p less than 0.005). The mean initial ejection fraction for the survivors was 0.32 +/- 0.04, and their mean end systolic and end diastolic ventricular volumes were substantially increased with a normal stroke volume. The survivors' serial scans showed a gradual return to normal ejection fraction and ventricular volume by 10 days after the onset of shock. Nonsurvivors had normal initial ejection fractions and ventricular volumes that did not change during serial studies.
1,284Â citations
TL;DR: Excessive formation of both types of nonenzymatic glycosylation product appears to be the common biochemical link between chronic hyperglycemia and a number of pathophysiologic processes potentially involved in the development of long-term diabetic complications.
Abstract: Glucose chemically attaches to proteins and nucleic acids without the aid of enzymes. Initially, chemically reversible Schiff base and Amadori product adducts form in proportion to glucose concentration. Equilibrium is reached after several weeks, however, and further accumulation of these early nonenzymatic glycosylation products does not continue beyond that time. Subsequent reactions of the Amadori product slowly give rise to nonequilibrium advanced glycosylation end-products which continue to accumulate indefinitely on longer-lived molecules. Excessive formation of both types of nonenzymatic glycosylation product appears to be the common biochemical link between chronic hyperglycemia and a number of pathophysiologic processes potentially involved in the development of long-term diabetic complications. The major biological effects of excessive nonenzymatic glycosylation include: inactivation of enzymes; inhibition of regulatory molecule binding; crosslinking of glycosylated proteins and trapping of soluble proteins by glycosylated extracellular matrix (both may progress in the absence of glucose); decreased susceptibility to proteolysis; abnormalities of nucleic acid function; altered macromolecular recognition and endocytosis; and increased immunogenicity.
1,067Â citations
TL;DR: Doctors play an active role in regulating the quantity of information elicited at the beginning of the clinical encounter, and use closed-ended questioning to control the discourse, resulting in the premature interruption of patients.
Abstract: Determining the patient's major reasons for seeking care is of critical importance in a successful medical encounter. To study the physician's role in soliciting and developing the patient's concerns at the outset of a clinical encounter, 74 office visits were recorded. In only 17 (23%) of the visits was the patient provided the opportunity to complete his or her opening statement of concerns. In 51 (69%) of the visits the physician interrupted the patient's statement and directed questions toward a specific concern; in only 1 of these 51 visits was the patient afforded the opportunity to complete the opening statement. In six (8%) return visits, no solicitation whatever was made. Physicians play an active role in regulating the quantity of information elicited at the beginning of the clinical encounter, and use closed-ended questioning to control the discourse. The consequence of this controlled style is the premature interruption of patients, resulting in the potential loss of relevant information.
886Â citations
TL;DR: Although early trials showed marked gastrointestinal and renal toxicities, treatment-related morbidity has been significantly alleviated with modern antiemetic therapy and adequate pretreatment hydration.
Abstract: Cisplatin is a metal coordination compound that was approved for clinical use in treating testicular cancer 5 years ago. Although early trials showed marked gastrointestinal and renal toxicities, treatment-related morbidity has been significantly alleviated with modern antiemetic therapy and adequate pretreatment hydration. More recent clinical studies of cisplatin have shown a broad range of activity and provide a better understanding of the drug's pharmacology, mechanism of action, and toxicity. Variations in the dosage and mode of administration as well as development of cisplatin analogues are being currently studied.
879Â citations
TL;DR: The acquired immunodeficiency syndrome is a new disease whose cause is unknown but is almost surely due to a transmissible agent, most likely a virus.
Abstract: The acquired immunodeficiency syndrome is a new disease whose cause is unknown but is almost surely due to a transmissible agent, most likely a virus. The disease is clearly spread by sexual contact, particularly homosexual activity. Blood-borne transmission constitutes the other major recognized form of spread of the disease, although it is highly likely that the disease is not readily spread through casual, nonsexual, non-blood-borne routes. Although the disease is still highly concentrated in the United States, it is now seen in several countries throughout the world. The common denominator of the disease is a profound suppression of cell-mediated immunity, specifically a quantitative and qualitative defect in the T4 inducer or helper subset of T lymphocytes. Hyperactivity of B lymphocytes is also characteristic. The clinical manifestations are those of severe and life-threatening opportunistic infections and unusual neoplasms, particularly Kaposi's sarcoma. The mortality may well approach 100%, making this one of the most extraordinary transmissible diseases in history.
800Â citations
TL;DR: Survivors with the acquired immunodeficiency syndrome at initial presentation had a significantly lower respiratory rate, and higher room air arterial oxygen tension, lymphocyte count, and serum albumin level compared to nonsurvivors.
Abstract: Clinical features of 49 episodes ofPneumocystis cariniipneumonia in patients with the acquired immunodeficiency syndrome were compared with those of 39 episodes in patients with other immu...
774Â citations
TL;DR: The problem of patient compliance, as well as the ability of the physician to understand, detect, and improve compliance are described in relation to a new model of health decisions and patient behavior.
Abstract: The problem of patient compliance, as well as the ability of the physician to understand, detect, and improve compliance, are described in relation to a new model of health decisions and p...
763Â citations
TL;DR: For patients with acute leukemia, granulocytopenia persisting longer than three weeks is the major risk factor for developing invasive pulmonary aspergillosis.
Abstract: A case-control study of patients with acute leukemia was done to identify significant risk factors for invasive pulmonary aspergillosis by reviewing the medical histories of 15 cases of pathologically proven invasive pulmonary aspergillosis and 45 controls. A history of lung or sinus disease, smoking, and multiple recurrences of leukemia did not increase the risk of invasive pulmonary aspergillosis. Cases and controls received similar chemotherapeutic regimens, and exposure to aminoglycosides, carbenicillin, trimethoprim-sulfamethoxazole, or corticosteroids was not significantly associated with development of invasive pulmonary aspergillosis. Among the factors tested, only granulocytopenia was associated with development of invasive pulmonary aspergillosis. Early in the course of granulocytopenia, patients developed signs of invasive pulmonary aspergillosis at a rate of approximately 1% per day. As the duration of granulocytopenia increased, the rate increased, approximating 4.3% per day between the 24th and 36th days. Of the 13 patients remaining granulocytopenic at 28 days, 7 had developed signs of invasive pulmonary aspergillosis. For patients with acute leukemia, granulocytopenia persisting longer than three weeks is the major risk factor for developing invasive pulmonary aspergillosis.
706Â citations
TL;DR: In patients with the acquired immunodeficiency syndrome, trimethoprim-sulfamethoxazole has a higher incidence of adverse reactions than pentamidine and appears earlier than toxicity associated withpentamidine.
Abstract: We reviewed the charts of 38 patients with the acquired immunodeficiency syndrome who were treated for Pneumocystis carinii pneumonia. Only 5 of 37 patients started on trimethoprim-sulfamethoxazole were able to complete treatment; in 29 patients drug toxicity occurred and in 19 treatment was changed due to adverse reactions that included rash, fever, neutropenia, thrombocytopenia, and transaminase elevation. Pentamidine was given to 30 patients (1 as initial treatment); toxicity occurred in 13 but only 4 required a change in drug. Adverse reactions from pentamidine included fever, rash, neutropenia, transaminase elevation, azotemia, and hypoglycemia. Patients received trimethoprim-sulfamethoxazole a median of 9.5 days, and pentamidine, a median of 12.5 days. Toxicity from trimethoprim-sulfamethoxazole appeared earlier than toxicity associated with pentamidine (7.5 versus 9.5 days of treatment). In patients with the acquired immunodeficiency syndrome, trimethoprim-sulfamethoxazole has a higher incidence of adverse reactions than pentamidine (p less than 0.005).
646Â citations
TL;DR: A computer-stored medical record system containing a limited set of the total clinical data base--primarily diagnostic studies and treatments responds to its own content according to physician-authored reminder rules according to 1490 rules on physician behavior.
Abstract: We developed a computer-stored medical record system containing a limited set of the total clinical data base--primarily diagnostic studies and treatments. This system responds to its own content according to physician-authored reminder rules. To determine the effect of the reminder messages generated by 1490 rules on physician behavior, we randomly assigned practitioners in a general medicine clinic to study or control groups. The computer found indications for six different actions per patient in 12 467 patients during a 2-year study: 61 study group residents who received computer reminders responded to 49% of these indications; 54 control group residents, to only 29% (p less than 0.0001). Preventive care (occult blood testing, mammographic screening, weight reduction diets, influenza and pneumococcal vaccines) was affected. The intentions of the study group to use a given action for an indication predicted their response to the indications (p less than 0.03, r2 = 0.33). The intentions of the control residents did not.
594Â citations
TL;DR: Preliminary data suggest that inhibition of the sympathetic nervous system may be helpful, and inhibition of vasopressin in animals with heart failure is being studied, and data indicate that selective blockade of the renin-angiotensin system is useful.
Abstract: The incidence of congestive heart failure is increasing in the United States. This common syndrome is characterized not only by impaired ventricular function but also by an increase in some endogenous vasoconstrictor substances, including norepinephrine, angiotensin II, and arginine vasopressin. Although activation of the systems that release these substances is presumed to be compensatory (to maintain perfusion pressure during inadequate flow), the sympathetic nervous system, renin-angiotensin-aldosterone system, and arginine vasopressin may contribute to the pathogenesis of the syndrome. The excessive vasoconstriction present in heart failure likely produces a further burden on the failing myocardium. New strategies in therapy are being developed to counteract the activation of vasoconstrictor forces in congestive heart failure. Data indicate that selective blockade of the renin-angiotensin system is useful. Preliminary data suggest that inhibition of the sympathetic nervous system may be helpful, and inhibition of vasopressin in animals with heart failure is being studied. New and more selective therapy for heart failure may come from these studies.
TL;DR: Lower initial doses of cyclosporine, followed by more rapid tapering may reduce the incidence of nephrotoxicity without compromising improved graft outcome.
Abstract: Cyclosporine, a cyclic endecapeptide of fungal origin, has recently been released for use in clinical transplantation. Trials in kidney, heart, liver and bone marrow recipients were encouraging: 1-year graft survival rates were 70% to 80% for kidney and heart recipients, and 60% to 65% for liver allograft recipients. Cyclosporine is also effective in treating bone marrow recipients with acute graft-versus-host disease. The drug selectively inhibits T-helper cell production of growth factors essential for B cell and cytotoxic T-cell differentiation and proliferation, while allowing expansion of suppressor T-cell populations. Drug absorption varies greatly, necessitating monitoring of drug level and individualization of therapy. Nephrotoxicity is the most frequent side effect of cyclosporine. An increased incidence of B-cell lymphomas seen when cyclosporine was used in conjunction with cytotoxic agents or anti-lymphocyte globulin has very rarely been observed when concomitant immunosuppression has been limited to low-dose corticosteroids. Lower initial doses of cyclosporine, followed by more rapid tapering may reduce the incidence of nephrotoxicity without compromising improved graft outcome.
TL;DR: The histologic findings suggest that a specific pathologic process occurs in the lamina propria of the small intestine and colon in some patients with the acquired immunodeficiency syndrome.
Abstract: To explore the effect of the acquired immunodeficiency syndrome on gastrointestinal structure and absorption, the cases of 12 homosexual men with the syndrome and 11 homosexual controls were studied. Seven patients had diarrhea with weight loss. Bacterial or parasitic infections were not detected. All patients were malnourished; had significantly fewer T-lymphocyte helper and suppressor cells; and had significantly lower body weights, midarm circumferences, serum albumin concentrations, and iron binding capacities than homosexual controls. D-Xylose malabsorption and steatorrhea were present in patients, especially those with diarrhea. Jejunal and rectal biopsy samples were histologically abnormal in all patients with diarrhea. Jejunal abnormalities included partial villus atrophy with crypt hyperplasia and increased numbers of intraepithelial lymphocytes. Rectal abnormalities included intranuclear viral inclusions, mast cell infiltration in the lamina propria, and focal cell degeneration near the crypt base. The histologic findings suggest that a specific pathologic process occurs in the lamina propria of the small intestine and colon in some patients with the syndrome.
TL;DR: In this paper, the authors estimated that more than half of the decline in ischemic heart disease mortality between 1968 and 1976 was related to changes in lifestyle, specifically to reductions in serum cholesterol levels and cigarette smoking.
Abstract: Using reasonable assumptions gathered from the published literature, we estimated that more than half of the decline in ischemic heart disease mortality between 1968 and 1976 was related to changes in lifestyle, specifically to reductions in serum cholesterol levels and cigarette smoking. In comparison, about 40% of the decline can be directly attributed to specific medical treatment of clinical ischemic heart disease and hypertension being the leading estimated contributors. Because many of these interventions have not yet been applied to their maximum potential, a continued decline in mortality rates might be anticipated in the coming decades. However, the relative costs of these medical interventions and lifestyle changes and the extent to which they interact with each other must be considered before an optimal national health strategy can be derived.
TL;DR: Bronchoalveolar lavage is a valuable procedure for evaluation of pulmonary disease in the immunosuppressed host and could be combined with those of transbronchial biopsies, brushings, and washings in the diagnosis of most of the diseases.
Abstract: The usefulness of bronchoalveolar lavage in the diagnosis of pulmonary infiltrates in the immunosuppressed patient was studied in 97 patients. In immunosuppressed patients, the available d...
TL;DR: Oral anticoagulants could be started concomitantly with the heparin so that it could be discontinued in several days, and this approach may prevent most episodes of heparIn-associated thrombocytopenia.
Abstract: Heparin-associated thrombocytopenia is a relatively common complication of heparin therapy occurring in approximately 5% of the patients who receive this drug. The incidence is higher with bovine heparin then with porcine heparin. Onset of heparin-associated thrombocytopenia usually occurs 6 to 12 days after initiation of treatment and by itself has a low morbidity. Heparin-associated thrombocytopenia plus arterial thrombosis can cause major complications including stroke, heart attack, and death. The incidence of heparin-associated thrombocytopenia plus arterial thrombosis is lower than that for heparin-associated thrombocytopenia alone. The diagnosis of heparin-associated thrombocytopenia remains one of exclusion, but testing for the presence of a heparin-dependent platelet-aggregating factor may prove to be useful. Analysis of the time of onset suggests a strategy for prevention. Oral anticoagulants could be started concomitantly with the heparin so that it could be discontinued in several days. This approach may prevent most episodes of heparin-associated thrombocytopenia.
TL;DR: L-Thyroxine therapy may be useful for patients with subclinical hypothyroidism with abnormal myocardial contractility or symptoms consistent with mild hypothy thyroid hormone action, or both.
Abstract: The indications for treating patients with subclinical hypothyroidism (normal serum thyroxine and free thyroxine levels, but elevated serum thyrotrophin levels) are poorly defined. In this study, 33 patients with subclinical hypothyroidism were randomly assigned in a double-blind manner to receive placebo or L-thyroxine therapy and were followed for 1 year with thyroid function tests, serum lipid measurements, basal metabolic rate and systolic time interval determinations, and a questionnaire on hypothyroid symptoms. The placebo group showed no changes in thyroid function or peripheral indices of thyroid hormone action. In the thyroxine-treated group, serum lipids and the mean systolic time interval did not change, but the systolic time intervals became normal in the 5 patients with the most abnormal baseline values. Symptoms improved in 8 of 14 patients receiving thyroxine and in 3 of 12 patients receiving placebo (p less than 0.05). L-Thyroxine therapy may be useful for patients with subclinical hypothyroidism with abnormal myocardial contractility or symptoms consistent with mild hypothyroidism, or both.
TL;DR: Patients are attracted to therapeutic alternatives that reflect social emphasis on personal responsibility, pollution and nutrition, and that move away from perceived deficiencies in conventional medical care.
Abstract: Public education, legislative action, and medical advances have failed to deter patients from seeking unorthodox treatments for cancer and other diseases. To study this phenomenon, we interviewed 304 cancer center inpatients and 356 patients under the care of unorthodox practitioners. A concomitant survey of unorthodox practitioners documented their backgrounds and practices. Eight percent of all patients studied never received any conventional therapy, and 54% of patients on conventional therapy also used unorthodox treatments. Forty percent of patients abandoned conventional care entirely after adopting alternative methods. Patients interviewed did not conform to the stereotype of poorly educated, end-stage patients who had exhausted conventional treatment. Practitioners also deviated from the traditional portrait: Of 138 unorthodox practitioners studied, 60% were physicians(M.D.s). Patients are attracted to therapeutic alternatives that reflect social emphasis on personal responsibility, pollution and nutrition, and that move away from perceived deficiencies in conventional medical care.
TL;DR: Risk factors for nephrotoxicity in patients treated with aminoglycosides were determined from the case records of 214 patients in two prospective, randomized clinical trials of gentamicin and tobramycin and generated an equation that was accurate in discriminating between patients with and without neph rotoxicity when validated in an independent population.
Abstract: Risk factors for nephrotoxicity in patients treated with aminoglycosides were determined from the case records of 214 patients in two prospective, randomized clinical trials of gentamicin and tobramycin. Nephrotoxicity, defined as a 50% or greater fall in calculated creatinine clearance, developed in 30 patients (14.1%). Patients with nephrotoxicity had higher initial calculated creatinine clearances, were more often women, and were more likely to have liver disease. Using stepwise discriminant analysis, these factors were selected with the initial 1-hour post-dose aminoglycoside level, patient age, and shock. An equation was generated that was accurate in discriminating between patients with and without nephrotoxicity when validated in an independent population. Factors that did not add significantly to the equation were diabetes, dehydration, serum bicarbonate, bacteremia, urinary tract infection, gentamicin or tobramycin use, duration of therapy, total aminoglycoside dose, or the use of clindamycin, furosemide, or cephalothin.
TL;DR: Tuberculosis preceded the syndrome by 1 to 17 months (mean, 6) in 22 patients, and in 10 patients with the syndrome and positive sputum cultures who were treated with conventional antituberculosis drugs, the cultures became negative within 1 to 4 months and tuberculosis did not recur.
Abstract: To study the association between mycobacterial disease and the acquired immunodeficiency syndrome, we reviewed the records of all cases of tuberculosis and all cases of the syndrome reported in Dade County, Florida, from January 1980 through June 1983. Tuberculosis was diagnosed in 27 of 45 Haitians with the syndrome, but in only 1 of 37 non-Haitians with the syndrome (p less than 0.001). Among the 27 Haitians with the syndrome and tuberculosis, 19 had extrapulmonary tuberculosis, whereas among 286 Haitian patients with tuberculosis without the syndrome, only 56 had extrapulmonary tuberculosis (p less than 0.001). Tuberculosis preceded the syndrome by 1 to 17 months (mean, 6) in 22 patients. In 10 patients with the syndrome and positive sputum cultures who were treated with conventional antituberculosis drugs, the cultures became negative within 1 to 4 months and tuberculosis did not recur. The frequency of disseminated atypical mycobacteriosis or positive sputum cultures for atypical mycobacteria was not significantly different between Haitian (11.3%) and non-Haitian (8.3%) patients with the syndrome.
TL;DR: In patients receiving chronic amiodarone therapy, clinically suspected hyperthyroidism is best confirmed by showing elevations in serum T3 or free T3 concentrations; hypothyroidistan is best diagnosed by showing an elevated serum thyrotrophin concentration.
Abstract: Amiodarone, an iodine-containing drug used frequently in the treatment of cardiac arrhythmias and angina pectoris, has many effects on thyroid hormone metabolism, including decreasing the production of triiodothyronine (T3) and decreasing the clearance of thyroxine and reverse T3. These effects result in elevated serum thyroxine and reverse T3 concentrations and decreased serum T3 concentrations. In addition, iodine-induced hyperthyroidism or hypothyroidism may occur in patients chronically treated with amiodarone. This study is a retrospective analysis of the incidence of thyroid dysfunction in Lucca and Pisa, West Tuscany, Italy, and in Worcester, Massachusetts. Hyperthyroidism was a more frequent (9.6%) complication of amiodarone therapy in West Tuscany, where iodine intake is moderately low; hypothyroidism was more frequent (22%) in Worcester, where iodine intake is sufficient. In patients receiving chronic amiodarone therapy, clinically suspected hyperthyroidism is best confirmed by showing elevations in serum T3 or free T3 concentrations; hypothyroidism is best diagnosed by showing an elevated serum thyrotrophin concentration. Thyroid function should be carefully monitored in patients receiving amiodarone chronically, especially if they have goiter or Hashimoto's thyroiditis.
TL;DR: High-dose cisplatin in combination with vinblastine, bleomycin, and VP-16 produced an 88% complete response rate in these high-risk patients who are characterized primarily by the presence of advanced bulky lung and abdominal disease.
Abstract: To overcome the dose limiting toxicity of cisplatin we have administered high-dose cisplatin (200 mg/m2body surface area in five divided daily doses with each dose administered in 250 mL o...
TL;DR: Results show that chronic exposure to foreign antigens may be associated with abnormalities of immunologic function, but that chronically transfused patients do not have the same immunologic profile as reported in some homosexuals and hemophiliacs.
Abstract: Concern for the potential risk of the acquired immunodeficiency syndrome among blood cell recipients led us to measure immunologic functions in patients who had received multiple transfusions. Abnormalities of two immunologic tests, natural killer cell function and helper/suppressor (T4/T8) lymphocyte subpopulation ratio, have characterized patients with the acquired immunodeficiency syndrome and are prevalent in populations at risk for this syndrome. Natural killer cell function was severely depressed in multiply transfused patients. However, T4/T8 ratios were normal in this population. The role of chronic antigenic stimulation was studied by measurement of HLA-DR expression on T cells. The expression of HLA-DR antigen is markedly elevated in multiply transfused patients. These results show that chronic exposure to foreign antigens may be associated with abnormalities of immunologic function, but that chronically transfused patients do not have the same immunologic profile as reported in some homosexuals and hemophiliacs.
TL;DR: Six patients with Kaposi's sarcoma, four at high dose and two at low dose, had objective responses (complete or partial) to treatment, however, therapy did not appear to eradicate cytomegalovirus carriage or prevent opportunistic infections related to cytomeGalovirus.
Abstract: In a randomized prospective study we tested the toxicity and efficacy of recombinant alpha-2 interferon in the treatment of Kaposi's sarcoma associated with the acquired immunodeficiency syndrome. High doses (50 X 10(6) U/m2 body surface area, intravenously) or low doses (1 X 10(6) U/m2, subcutaneously) of recombinant alpha-2 interferon were administered to 20 patients for 5 days/wk, every other week, for four treatment cycles. Therapy was well tolerated subjectively and caused only mild hematologic and hepatic toxicity at both dose levels. No consistent or sustained changes were seen in immunologic variables during or after treatment. Six patients with Kaposi's sarcoma, four at high dose and two at low dose, had objective responses (complete or partial) to treatment. However, therapy did not appear to eradicate cytomegalovirus carriage or prevent opportunistic infections related to cytomegalovirus.
TL;DR: Between January 1982 and December 1983, 75 patients with the acquired immunodeficiency syndrome were identified in hospitals: 35% used intravenous drugs, 50% had proteinuria in excess of 0.5 g/dL, and 10% were nephrotic.
Abstract: Between January 1982 and December 1983, 75 patients with the acquired immunodeficiency syndrome were identified in our hospitals: 35% used intravenous drugs, 50% had proteinuria in excess of 0.5 g/dL, and 10% were nephrotic. Glomerular changes seen at autopsy in 36 patients included frequent mesangial lesions and deposits associated with mild asymptomatic proteinuria. Focal and segmental glomerular sclerosis was found in 5 patients and 4 of these had the nephrotic syndrome. Whereas reversible episodes of acute renal failure were not uncommon, terminal episodes of acute renal insufficiency occurred in 14 patients. The short survival of these patients may prevent the development of chronic renal failure.
TL;DR: The authors' data suggest that the incidence of non-A, non-B hepatitis might have been reduced by about one third by screening of donors for anti-HBc, however, elevated ALT levels in donors had a similar association with non- A, non -B hepatitis in recipients but would have resulted in fewer units of blood being discarded than would screening forAnti- HBc.
Abstract: Patients who received transfusions and nontransfused control patients were followed to assess the incidence and cause of post-transfusion hepatitis and to identify donor factors that might relate to risk of hepatitis. We evaluated as risk factors in donors the presence of antibody to hepatitis B virus compared with elevated alanine aminotransferase (ALT) level. Units of blood that were positive for antibody to hepatitis B core antigen (anti-HBc) were associated with a twofold to threefold greater risk of non-A, non-B hepatitis in the recipients than were units without anti-HBc. In the absence of specific serologic tests for non-A, non-B agents, screening of donors for anti-HBc might be considered. Our data suggest that the incidence of non-A, non-B hepatitis might have been reduced by about one third by such screening. However, elevated ALT levels in donors had a similar association with non-A, non-B hepatitis in recipients but would have resulted in fewer units of blood being discarded than would screening for anti-HBc.
TL;DR: It is concluded that patients with histories of repeated systemic infections are at risk for the development of abnormalities of the B-lymphocytic system, manifested by abnormal hyper-B-cell response in enlarged reactive lymph nodes and aggressive, extranodal B-cell lymphomas.
Abstract: Serious infections, neoplasms, and immunologic abnormalities have been found in homosexual men. We describe the development of malignant lymphoma in six such patients, three of whom had pe...
TL;DR: High-dose recombinant leukocyte A interferon preparation is highly effective in the treatment of advanced refractory cutaneous T-cell lymphomas, and new schedules to reduce toxicity and achieve complete responses, combined treatment with chemotherapy or serotherapy, and its use in earlier stages of disease should be investigated.
Abstract: High-dose recombinant leukocyte A interferon (50 X 10(6) U/m2 body surface area, intramuscularly, three times weekly) was tested in a clinical trial involving patients with advanced cutaneous T-cell lymphomas to determine its effectiveness and toxicity. All 20 patients had advanced stages of disease refractory to two or more standard therapies. Objective partial remissions lasting 3 months to more than 25 months (median, 5 months) were documented in 9 patients. The major dose-limiting toxicity was a severe influenza-like syndrome with malaise, anorexia, depression, weight loss, and decreased performance status; this effect was reversible after dose reductions in all patients and did not recur with re-escalation of doses in 10 patients. This interferon preparation is highly effective in the treatment of advanced refractory cutaneous T-cell lymphomas, and new schedules to reduce toxicity and achieve complete responses, combined treatment with chemotherapy or serotherapy, and its use in earlier stages of disease should be investigated.
TL;DR: Survival data from 379 patients with chronic hepatitis B were analyzed to determine life expectancy for the patient from the time of first contact, and a multivariate analysis found age of 40 years or more, total bilirubin level of 1.5 mg/dLor more, ascites, and spider nevi to be factors that identified patients at a higher risk of death.
Abstract: Survival data from 379 patients with chronic hepatitis B were analyzed to determine life expectancy for the patient from the time of first contact. One hundred twenty-one patients had chronic persistent hepatitis, 128 had chronic active hepatitis, and 130 had chronic active hepatitis with cirrhosis. The frequency of symptoms (p less than 0.001), stigmata of chronic liver disease (p less than 0.001), and liver function test abnormalities (p less than 0.001) increased as the histologic features worsened, whereas the percentage of patients with circulating hepatitis B DNA polymerase declined (p less than 0.001). Women were uncommon in our series and had less severe disease than men (p less than 0.02). Fifty-one patients had died by the time of this analysis. The estimated 5-year survival rates were 97% for patients with chronic persistent hepatitis, 86% for those with chronic active hepatitis, and 55% for those with chronic active hepatitis with cirrhosis. The usual cause of death was liver failure and its sequelae. A multivariate analysis found age of 40 years or more, total bilirubin level of 1.5 mg/dL or more, ascites, and spider nevi to be factors that identified patients at a higher risk of death. The prognosis for patients with chronic hepatitis B is similar to that for patients with chronic hepatitis of other causes.
TL;DR: Elevated levels of calcitriol, an active vitamin D metabolite, occurred in the presence of significant renal impairment and relative parathyroid suppression and responded to glucocorticosteroid therapy.
Abstract: A radioreceptor assay for serum 1,25-dihydroxyvitamin D (calcitriol) was used to screen patients with hypercalcemia of malignancy. Three patients with non-Hodgkin's lymphoma and hypercalcemia (serum Ca, 12.0, 13.4, and 13.0 mg/dL, respectively) had increased serum calcitriol levels (56, 72, and 77 pg/mL, respectively; normal, less than 50 pg/mL). Elevated levels of calcitriol, an active vitamin D metabolite, occurred in the presence of significant renal impairment (creatinine clearance, 8 to 19 mL/min) and relative parathyroid suppression (serum immunoreactive parathyroid hormone, 17 to 39 microL-eq/mL; mean value in end-stage renal disease, 182 +/- 39 microL-eq/mL). Hypercalcemia and excessive serum calcitriol levels responded to glucocorticosteroid therapy. In two patients, the hypercalcemia and increased serum calcitriol level were related to a tumor, but not to the serum immunoreactive parathyroid hormone level. Fractional intestinal 47Ca absorption, measured in one patient, was increased (0.94; normal, less than 0.61) and varied directly with the serum calcitriol level. No patient had evidence of sarcoidosis. Hypercalcemia associated with certain lymphomas may be caused by the increased synthesis of calcitriol by lymphoma cells.