Showing papers in "JAMA in 1976"

Prevalence of malnutrition in general medical patients.

Abstract: Three, single-day nutritional surveys at weekly intervals were conducted in the general medical wards of an urban municipal teaching hospital. The techniques of nutritional assessment included anthropometric measures (weight/height, triceps skin fold, arm-muscle circumference, serum albumin, and hematocrit). The prevalence of protein-calorie malnutrition was 44% or greater by these criteria (weight/height, 45%; triceps skin fold, 76%; arm-muscle circumference, 55%; serum albumin, 44%; and hematocrit, 48%). These results were reproducible without significant variation between surveys. In 34% of patients, a lymphopenia of 1,200 cells/cu mm or less was found, a level likely to be associated with diminished cell-mediated immunity. Compared with a similar survey among surgical patients, the medical patients were more depleted calorically (weight/height, triceps skin fold) but had better protein status (arm-muscle circumference, serum albumin). Significant protein-calorie malnutrition occurs commonly in municipal hospitals in both medical and surgical services. (JAMA235:1567-1570, 1976)

Secundum Atrial Septal Defect: Nonoperative Closure During Cardiac Catheterization

Abstract: A 17-year-old girl had clinical and cardiac catheterization findings compatible with a secundum atrial septal defect. During cardiac catheterization, the atrial septal defect was sized and closed using a transvenous umbrella technique. (JAMA235:2506-2509, 1976)

Endoscopic Complications: Results of the 1974 American Society for Gastrointestinal Endoscopy Survey

Abstract: Esophagogastroduodenoscopy (211,410 examinations) had a complication rate of 1.3/1,000 cases. Duodenoscopy with cannulation was performed 3,884 times and had a complication rate of 21.6/1,000 examinations. Diagnostic coloscopy (25,298 examinations) had a complication rate of 3.4/1,000. Polypectomies during coloscopy (6,124 cases) had a complication rate of 23.3/1,000 cases. Esophageal dilations (13,139 cases) had a complication rate of 4.25 with mercury bougies, and in 9,431 cases metal olives produced a complication rate of 6.1/1,000 treatments. Dilation for achalasia in 1,224 patients produced a complication rate of 18.4/1,000 procedures. Peritoneoscopy (4,404 examinations) produced a complication rate of 5.4/1,000 patients. The value of these diagnostic and therapeutic procedures is now well established but must be weighed against a potential risk of complications. ( JAMA 235:928-930, 1976)

Mortality in patients treated for pulmonary embolism

Abstract: The hospital course of 144 consecutive patients with pulmonary embolism (PE) demonstrated by pulmonary angiography was reviewed to determine the mortality of patients with treated PE. Twelve patients (8%) died of PE, and eight died of causes other than PE; 124 (86%) survived. Pulmonary embolism was the primary cause of death in only four of the 12 patients who died of PE. Pulmonary embolism contributed to the death of eight other patients, each of whom had associated potentially lethal disease, particularly heart disease. The most important factor affecting mortality was shock due to acute right ventricular failure secondary to massive PE (mortality, 32%). Mortality was not related to magnitude of PE per se; the mortality of patients with massive PE without shock (6%) was the same as that for patients with submassive PE (5%). Patients with PE who survive long enough to have the diagnosis established and appropriate prophylactic therapy begun have an excellent prognosis, unless they have associated severe medical disease. ( JAMA 236:1477-1480, 1976)

Fetal Alcohol Syndrome: Experience With 41 Patients

Abstract: Forty-one patients with the fetal alcohol syndrome, including 11 whose cases were previously reported, were studied. These children have a pattern of defects including prenatal and postnatal growth deficiency, small head size with mental subnormality, and facial abnormalities allowing for recognition of the disorder in infancy. The same pattern of abnormalities has been independently reported from France in a series of 127 offspring of chronic alcoholics. (JAMA235:1458-1460, 1976)

Hypertension screening of 1 million Americans. Community Hypertension Evaluation Clinic (CHEC) program, 1973 through 1975.

Abstract: During 1973 through 1975, more than 1 million persons were screened in the nationwide Community Hypertension Evaluation Clinic (CHEC) program at 1,171 sites. While those screened were not from defined populations, findings paralleled those of recent surveys of US population samples. First, CHEC confirmed the scope of the problem of elevated blood pressure in the United States. Of those screened, 247 of 1,000 had a diastolic reading of 90 mm Hg or higher; 116 of 1,000 had a reading of 95 mm Hg or greater. Prevalence of elevated blood pressure rose with age up to age 50 years, was higher in blacks than in whites, and was higher in men than in women. Second, CHEC data confirmed the challenge of undetected, untreated, and uncontrolled hypertension. Previously undetected hypertension was present in 27.7% of hypertensive people, detected but untreated in 10.7%, and treated but uncontrolled in 16.7%—totaling 55.1%. (JAMA235:2299-2306, 1976)

Treatment of Colorectal Cancer

Abstract: To the Editor.— This is in reference to the recent editorial by Drs Mavligit and Freireich entitled "Progress in the Treatment of Colorectal Cancer" (235:2855, 1976). I believe that their statement "treatment results have not improved much over the past two decades, in spite of surgery and radiotherapy" is incorrect and misleading. I agree that surgery has perhaps gone as far as it will and that no progress with this therapeutic modality has been made in the past 20 years. Much to the contrary, radiotherapy has increasingly improved results, and reports published within the last two decades clearly demonstrate this (231:1381, 1975; 231:1385, 1975). 1-3 In fact, the contributions of radiotherapy have been such that one can speak of cure by endocavitary irradiation in certain early tumors. It is very probable that radiotherapy is under-utilized nationwide, but that is a different problem. These comments are not to denigrate fluorouracil, which

Cough-induced cardiac compression. Self-administered from of cardiopulmonary resuscitation.

Abstract: Eight patients undergoing coronary angiography were successfully resuscitated from ventricular fibrillation (VF), and three of these patients remained conscious and alert for 24 to 39 seconds after VF by coughing every one to three seconds. The mean aortic systolic pressure induced by cough was 139.7 mm Hg (±3.8) and only 60.7 mm Hg (±5.1) by external cardiopulmonary resuscitation (CPR). Cough-CPR, accomplished by abrupt, forceful coughing maintains consciousness by rhythmic compression of the heart, has several advantages over external CPR in the catheterization laboratory, and may be applicable to other situations where serious rhythm disturbances are recognized before unconsciousness occurs. (JAMA236:1246-1250, 1976)

Clinical Experience With Theophylline: Relationships Between Dosage, Serum Concentration, and Toxicity

Abstract: Relationships between theophylline dosage, serum theophylline concentration, and theophylline toxicity were evaluated retrospectively in 47 hospitalized adults. The amount of theophylline administered daily varied more than sixfold, from 6 to 38 mg/kg. The serum theophylline concentrations, however, varied 24-fold from 2 to 49μg/ml. The relationship between daily dosage and serum concentration was unpredictable in an individual patient. Fourteen patients (30%) had a toxic reaction to theophylline. Toxic symptoms, which were not always gastrointestinal, occurred commonly with serum concentrations over 25μg/ml but were not noted with concentrations below 15μg/ml. High serum theophylline concentrations and a toxic reaction developed just as often with the oral route as when the drug was given intravenously. In six patients, measurement of serum theophylline concentration disclosed subtherapeutic concentrations. Serum theophylline determination appears to be important clinically in guiding effective and safe usage of theophylline. (JAMA235:1983-1986, 1976)

Tumor eradication by radiofrequency therapy. Responses in 21 patients.

Abstract: Tumor blood flow, measured by an isotope dilution technique, is only 2% to 15% of that of the surrounding tissue. This sluggish circulation differentiates cancer from normal tissue and forms the basis for a new therapy that entails the transfer of radiofrequency (RF) energy for heating tissues locally. The heated tissue is cooled by the circulation of blood, which carries away the heat. Impaired perfusion, as in cancers, impedes cooling. Heating by RF elevated the temperatures of animal and human cancers by 5 to 9.5 C above that of healthy tissue. The heat eradicated the animal cancers without destruction of normal tissue. Radiofrequency therapy produced tissue necrosis or substantial regression of cancer in 21 patients.

Physical Fitness Levels vs Selected Coronary Risk Factors: A Cross-Sectional Study

Abstract: Several studies show significant correlations of blood variables, weight, abnormal electrocardiograms, and blood pressure with the incidence of coronary heart disease, but the quantification of fitness and its correlation with coronary heart disease is more difficult. In this study, approximately 3,000 men, average age of 44.6 years, were examined for blood and lipid profile, pulmonary function, percent body fat determination, and Balke maximal performance treadmill stress testing with multilead ECG monitoring. Five age-adjusted cardiorespiratory fitness categories were determined from treadmill times. A consistent inverse relationship among physical fitness categories and resting heart rate, body weight, percent body fat, serum levels of cholesterol and triglycerides, glucose, and systolic blood pressure, was observed. Forced vital capacity was directly related to levels of fitness. These results, although cross-sectional, imply that physical fitness is related to lower coronary risk factors. ( JAMA 236:116-169, 1976)

Joint Study of Extracranial Arterial Occlusion: X. Internal Carotid Artery Occlusion

Abstract: One cannot now predict with accuracy the degree of deficit that may be anticipated following a carotid occlusion even when the condition of the opposite artery is known. When symptoms and signs occur, they are most likely related to the hemisphere or eye on the side of the occlusion. In patients with carotid occlusion, a higher rate of severe complications and mortality was encountered following arteriography than in the general study population. Among randomized patients with a carotid occlusion and a contralateral carotid stenosis, 63% of medically treated patients were alive at the end of a 66-month follow-up, whereas only 34% of surgically treated patients were still living. Surgical mortality was extremely high in patients with a carotid occlusion. Sixty-seven percent mortality occurred in patients undergoing surgery within one week of a cerebral infarction. ( JAMA 235:2734-2738, 1976)

Rates of cutaneous reactions to drugs. A report from the Boston Collaborative Drug Surveillance Program.

Abstract: Rates of allergic skin reactions to commonly used drugs were estimated from data obtained on 22,227 consecutively monitored medical inpatients. A total of 57 drugs were implicated with skin reactions. Five or more reactions were attributed to each of 22 drugs (or drug groups). Many commonly used drugs did not appear to cause any allergic reactions. The study provides the practicing physician with drug-specific quantitative data that can be used to evaluate the causes of drug-induced rash, itching, or hives.

The FeNa Test: Use in the Differential Diagnosis of Acute Renal Failure

Abstract: The FENa test, a determination of the excreted fraction of the filtered sodium, was performed in patients in the oliguric phase of acute renal failure. Patients with prerenal azotemia had an FENa of less than 1, and patients with acute tubular necrosis had an FENa of more than 3 (P less than .001). This simple test clearly differentiates between these two conditions and, thus, is of considerable clinical value.

Aspergillus Infections in Cancer Patients: Association With Fireproofing Materials in a New Hospital

Abstract: INFECTION is the major cause of mortality in patients with acute leukemia and lymphoma. 1-3 Among infections in patients with altered host defenses, an increasing incidence of such fungal complications is well established. 4-6 Fungal infections caused by Aspergillus spp are second in frequency only to candidiasis in these patient populations. 3-5,7 When present, Aspergillus infections are the major contributory factor to their demise, 6,8 and are of serious consequence in patients receiving immunosuppressive therapy for other circumstances, such as collagen vascular diseases, 9 renal transplants, 10 and cardiac transplants. 11 The Baltimore Cancer Research Center admits for intensive therapy patients with acute and chronic leukemia, lymphoma, multiple myeloma, brain tumors, metastatic sarcomas, and metastatic carcinomas. In the past six years there has been essentially no change in either the basic patient population or in treatment philosophy. The necropsy rate has remained consistently high. Shortly after relocation of the Center to

Intrinsic asthma in adults. Association with gastroesophageal reflux.

Abstract: Of 28 patients with severe asthma routinely examined with upper gastrointestinal (UGI) x-ray films, 18 (64%) were found to have hiatus hernia and 13 (46%) were found to have demonstrable gastroesophageal reflux. These prevalences differed significantly ( P These data suggest that aspiration of gastric acid is a frequent incitant to severe asthma and that it should be routinely sought in the treatment-resisant asthmatic patient. Intensive medical regimens directed against reflux and acidity may bring notable improvement in asthma symptoms. Surgical restoration of effective lower esophageal sphincter function has proved to be curative in other reported studies. ( JAMA 236:2626-2628, 1976)

Randomized Prospective Trial of Continuous vs Intermittent Heparin Therapy

Abstract: Forty-one patients with clinical indications for heparin therapy were randomized to receive continuous intravenous heparin sodium therapy or intermittent (four-hourly bolus) heparin therapy, with control by the activated partial thromboplastin time. Seven of 21 patients receiving intermittent therapy had major bleeding episodes, whereas none of the 20 patients receiving continuous heparin therapy had major bleeding (P = .005). One patient on continuous therapy had a pulmonary embolus, while none on intermittent therapy had recurrent thromboembolism. Two heavily bleeding patients on intermittent therapy were switched to continuous treatment after bleeding was controlled. The use of continuous heparin therapy appears significantly safer with regard to hemorrhagic complications than the use of intermittent therapy.

Diagnosis of That

Abstract: Few things are duller Than feeling unspecifically off-color, Yes, you feel like the fulfillment of a dismal prophecy, And you don't feel either exercisey or officey... Ogden Nash At any time of year, when a person ails vaguely in the head or the belly, or aches for no apparent reason and feels somewhat feverish, and mentions his symptoms to a friend or an acquaintance, the afflicted one is likely to hear, "Oh yes, there's a lot of that going around just now." The "that" remains as undefined as the sufferer's symptoms are ill-defined. The statement usually is made convincingly and consolingly, in an effort to reassure or with belief in the adage, "Misery loves company." Often, "that," offered as the sole diagnosis, does reassure and works wonders therapeutically when swallowed with a couple of aspirin tablets or the patient's favorite brand of sedative. Other times, "that" is not enough. For

Pleural Effusion: A Diagnostic Dilemma

Abstract: The cause of pleural effusion in 108 of 133 patients was determined by laboratory tests and clinical examination; it was indeterminate in 25, even after complete diagnostic evaluation In 164 diagnostic thoracenteses, 136 cytologic examinations were done; the results were positive for cancer in 20 (15%) Five of 19 patients (26%) with bronchogenic cancer, 13 of 25 (52%) with metastatic cancer of the lung, and two of 20 (10%) with lymphoma had positive results on cytologic examination Of 143 routine bacterial cultures, only five were positive (3%) Of 103 mycobacterial and 76 fungal cultures, only one was positive in each instance Despite the high incidence of indeterminate diagnoses, we recommend that only measurement of protein content and cytologic examination be ordered routinely Our algorithm provides a logical, cost-effective approach to the diagnostic problem of pleural effusion ( JAMA 236:2183-2186, 1976)

Motor Speech Disorders

Abstract: The authors have limited consideration of motor speech disorders to dysarthrias of neurogenic nature. Aphasias (defined by the authors as problems of processing and symbolic formulation of the language code) are excluded. So are the deviant patterns of speech, such as developmental disorders of articulation and those disorders arising from structural impairments, such as cleft palate. A short but useful review of the basic motor process of speech production and its evaluation by clinical and other techniques is included. A more detailed description of relatively unfamiliar methods, such as palatography and videofluoroscopy would have been desirable. The neurologist will find the chapters on principles of neurologic function and hierarchy of motor organization rather basic. Other specialists may find these useful. On the other hand, many speech pathologists may find the section on motor speech examination somewhat devoid of detail. A disproportionately large space is allotted to the examination of the

Sodium bicarbonate administration during cardiac arrest. Effect on arterial pH PCO2, and osmolality.

Abstract: Arterial pH, Pco 2 , and osmolality were determined serially during cardiac resuscitation in patients and in dogs, with and without administration of sodium bicarbonate. These studies demonstrate that (1) in the absence of preexisting acidosis, severe acidosis can be prevented by adequate ventilation alone; (2) sodium bicarbonate administration results in a significant rise in arterial Pco 2 , which parallels the rise in pH despite adequate ventilation; (3) during prolonged cardiac arrest and resuscitation, there is a rise in arterial osmolality that is accentuated by sodium bicarbonate. These studies suggest that sodium bicarbonate should not be used during resuscitation (1) in the absence of effective hyperventilation or where carbon dioxide removal is inadequate despite adequate ventilation, (2) in repeated doses, without confirmation of substantial acidosis, or (3) when cardiac arrest has been of brief duration and preexisting acidosis is unlikely. These studies also point to the need for a reappraisal of other buffers that do not elevate the arterial Pco 2 . ( JAMA 235:506-509, 1976)

Large-Dose Bleomycin Therapy and Pulmonary Toxicity: A Possible Role of Prior Radiotherapy

Abstract: Bleomycin sulfate pulmonary toxicity was encountered in nine of 101 patients receiving high-dose therapy for widespread testicular cancer. The pulmonary presentation was separable into two categories: (1) an early or minimal form with dyspnea on exertion, minimal roentgenographic findings, and normal arterial partial pressure of oxygen at rest and (2) a severe form, with prominent roentgenographic findings and hypoxemia at rest. All five patients with the severe form died, while the remaining four patients with the minimal presentation recovered. Prior thoracic radiotherapy appeared to predispose to bleomycin pulmonary toxicity, as this complication developed in five of 12 patients receiving prior chest radiotherapy vs four of 89 not receiving radiotherapy (P (JAMA235:1117-1120, 1976)

Bacteriologic Diagnosis of Acute Pneumonia: Comparison of Sputum, Transtracheal Aspirates, and Lung Aspirates

Abstract: Bacteriologic analysis was performed on sputum, transtracheal aspirate (TA), and direct-needle aspirate of the lung (LA) obtained concurrently in each of 25 adult Navajo Indian patients with acute, community-acquired pneumonia. Although sputum reflected the organisms isolated from LA as frequently as did TA, multiple potential pathogens were recovered from all but five sputum specimens and from 27% of TA. Data collected suggest frequent tracheal contamination with potential pathogens and occasional multiple bacterial isolates from the LA of patients with acute pneumonia. Lung aspiration yielded single, definitive isolations more frequently than other sampling techniques did. ( JAMA 235:158-163, 1976)

The Clinical Course of Diabetic Nephropathy

Abstract: A retrospective record analysis of 112 juvenile-onset diabetics with nephropathy was conducted in order to determine their clinical course. The mean duration of diabetes at the onset of proteinuria was 17.3+/-6.0 years. Early renal failure appeared two years after the onset of protein-uria, and severe renal failure (mean serum creatinine level, 8.5+/-3.9 mg/100 ml) four years after the onset of proteinuria. The mean duration of life after the onset of severe renal failure was six months. The mortality was 53%, with 59% of the deaths attributable to renal failure and 36% to cardiovascular disease. All patients experienced progressive deterioration of renal function as well as the other complications of diabetes, the rate of progression being accelerated toward the end of the course. Juvenile onset diabetics should be considered for renal transplantation before the serum creatinine level reaches 8.5 mg/100 ml.

Methadone maintenance treatment. A ten-year perspective.

Abstract: TEN YEARS ago inThe Journal, we reported on the use of methadone hydrochloride to treat a small group of intractable heroin addicts The encouraging results of this pilot experiment suggested that larger-scale maintenance programs might provide a treatment alternative for a significant number of heroin addicts To some extent this expectation has been supported by the experience of clinicians using methadone in treatment programs throughout the United States and abroad Many thousands of former heroin addicts have been rehabilitated, but on balance today, it must be recognized that the projections of ten years ago were overly optimistic The great majority of heroin addicts in our cities remain on the streets, and the programs have lost their ability to attract them to treatment An unfortunate consequence of the early enthusiasm for methadone treatment is today's general disenchantment with chemotherapy for addicts What was not anticipated at the onset was the

Mixed Venous Oxygen Tension and Hyperlactatemia: Survival in Severe Cardiopulmonary Disease

Abstract: Mixed venous oxygen tension (P[unk]o2), cardiac output ([unk]), and arterial oxygen tension (Pao2) were measured in 20 patients with severe cardiac or pulmonary disease or both to determine which of these variables would best predict hyperlactatemia and survival. There was no correlation between Pao2and either hyperlactatemia or survival, possibly because all oxygen tensions were greater than 40 mm Hg. There was a good correlation between [unk] and both hyperlactatemia and survival, and a slightly better correlation between P[unk]o2and both hyperlactatemia and survival. Mixed venous oxygen tension, a reflection of both Pao2and [unk] was a better predictor of hyperlactatemia and death than either arterial Pao2or [unk] alone. It is also more easily measured and, therefore, more clinically useful than either [unk], as a predictor of anaerobiosis and survival, or blood lactate concentration, as a predictor of survival. A mixed venous oxygen tension below 28 mm Hg was usually associated with hyperlactatemia and was always associated with death. (JAMA236:570-574, 1976)

Neurosyphilis and penicillin levels in cerebrospinal fluid.

Abstract: Because neurosyphilis may progress despite therapy with the recommended penicillin regimens, 15 subjects with positive tests for syphilis in the serum and cerebrospinal fluid (CSF) were studied. All of these patients had CSF pleocytosis. Two received penicillin G (5 and 10 million units per day intravenously, respectively) and 13 received benzathine penicillin G, 3.6 million units per week intramuscularly; treatment lasted four weeks. During intravenous and after intramuscular penicillin therapy, a spinal tap was performed on all subjects; later, assays were done. Of two patients who received intravenous penicillin G, one had 0.3 mug/ml and the other had 2.4 mug/ml penicillin in the CSF. Twelve of 13 patients who received benzathine penicillin G had no detectable penicillin in the CSF; one patient had 0.1 mug/ml penicillin in the CSF.

Disposition of presumed coronary patients from an emergency room. A follow-up study.

Abstract: All patients with presumed coronary problems seen at the Chaim Sheba Medical Center during a one-year period were followed up. The fate of those who were not hospitalized and the factors contributing to the two types of erroneous decisions, ie, refusing hospitalization to those needing it and unnecessary hospitalization of others, were evaluated. Approximately 50% of the patients were not admitted. Myocardial infarctions were later diagnosed in 6% of these patients. Another 8% were eventually categorized as other cardiac emergencies. Ten percent of all patients subsequently diagnosed as having myocardial infarctions were not admitted. On the other hand, 56% of the patients whose cases were later not considered to have been emergencies were hospitalized unnecessarily. Previous hospitalization for cardiac disease played a major role in making an error of both types. Other factors influencing the physician's decision regarding the patients' disposition included their age, sex, ethnic origin, and the findings from the emergency room electrocardiogram. ( JAMA 236:941-943, 1976)

Cerebral ventricular enlargement. Chronic alcoholics examined by computerized tomography.

Abstract: Computerized tomography was used to measure cerebral ventricular size in hospitalized alcoholic patients, all of whom had evidence of liver disease Twelve alcoholic patients with neurologic symptoms such as withdrawal seizures, neuropathy, and drug overdose were included All these patients had normal results from the mental status examinations by the time of discharge Alcoholic patients had a much higher mean ventricular size compared to 60 control patients One third of the alcoholics had markedly enlarged ventricles as opposed to only one of the 60 controls ( JAMA 236:365-368, 1976)

Bacteriuria localization and response to single-dose therapy in women.

Abstract: One hundred women with bacteriuria had the infection localized by the "bladder-washout" technique. Thirty-six of the 39 with infection confined to the bladder were cured with a single intramuscular injection of 500 mg of kanamycin sulfate, whereas 47 of the 65 patients with infection originating from their upper tract relapsed almost immediately. None of the seven patients with abnormal pyelograms and associated upper tract infection was cured with kanamycin. These results support the hypothesis that bladder infections in women can be readily cured with a very short course of therapy. Women who relapse after a single injection of kanamycin almost always have renal infection. ( JAMA 235:1854-1856, 1976)