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Showing papers in "JAMA in 1981"


Journal ArticleDOI
27 Mar 1981-JAMA
TL;DR: It would appear that isolated systolic hypertension predisposes to stroke independent of arterial rigidity, and diastolic pressure adds little to risk assessment and in men, in this subgroup, appears unrelated to stroke incidence.
Abstract: Based on prospective data from the Framingham study relating systolic pressure, diastolic pressure, age, and pulse-wave configuration to future stroke incidence, it would appear that isolated systolic hypertension predisposes to stroke independent of arterial rigidity. The prevalence of isolated systolic hypertension increased with age and with the degree of blunting of the dicrotic notch in the pulse wave. Subjects with isolated systolic hypertension experienced two to four times as many strokes as did normotensive persons. While diastolic pressure is related to stroke incidence, in the subject with systolic hypertension, the diastolic component adds little to risk assessment and in men, in this subgroup, appears unrelated to stroke incidence. (JAMA1981;245:1225-1229)

521 citations


Journal ArticleDOI
20 Feb 1981-JAMA
TL;DR: The new, third edition of this classic is almost 100 pages longer than the previous one and represents what one could well call a textbook of diseases of the brain (as opposed to the rest of the nervous system); it might frighten the physicians most likely to benefit from the book's frequent perusal.
Abstract: The new, third edition of this classic is almost 100 pages longer than the previous one and represents what one could well call a textbook of diseases of the brain (as opposed to the rest of the nervous system). Such a title might be more appropriate. The authors must have found it extremely difficult to resist the temptation to achieve an exhaustive review of all conditions, even some of the most exotic and unusual, that may, on rare occasion, lead to stupor or coma. This successful endeavor to be comprehensive carries an inherent danger: it might frighten the physicians most likely to benefit from the book's frequent perusal, such as house officers, family practitioners, and emergency room physicians who will unquestionably and understandably be most concerned with the "how-to" portions of the volume, particularly since they are so clearly written and exquisitely instructive. The authors state that one of the

510 citations


Journal ArticleDOI
19 Jun 1981-JAMA
TL;DR: Over the last eight years, maternal consumption of alcohol has become recognized through extensive human and animal studies as a major fetal health hazard—a leading known cause of mental retardation.
Abstract: THERE has been concern since antiquity that the ingestion of alcohol by the pregnant woman could damage her unborn child. Modern scientific warnings about gestational alcoholism began with Sullivan in 1899,1Rouquette in 1957,2and Lemoine et al in 1967,3who all noted the increased rates of stillbirth, growth deficiency, and malformations among the offspring of alcoholic women. Alcohol teratogenesis was brought to widespread public attention by Jones et al4in 1973. These authors believed that alcohol could produce a specific recognizable pattern of malformation, which they termed "fetal alcohol syndrome" (FAS). Over the last eight years, maternal consumption of alcohol has become recognized through extensive human and animal studies as a major fetal health hazard—a leading known cause of mental retardation. Syndrome Recognition Variability in phenotype occurs in most dysmorphic syndromes. By clinical appearance alone, both false-positive and false-negative cases are found in conditions that

486 citations


Journal ArticleDOI
02 Oct 1981-JAMA
TL;DR: Training increased the incidence of oligomenorrhea and amenorrhea among both premenarche- and postmenarches-trained athletes, and metabolic and hormonal changes consequent to an increased lean/fat ratio may explain these findings.
Abstract: Age at menarche and menstrual periodicity of 21 college swimmers and 17 runners were studied in relation to the age of initiating training. The 18 premenarche-trained athletes had a mean menarcheal age of 15.1±0.5 years, whereas the 20 postmenarche-trained athletes had a mean menarcheal age of 12.8±0.2 years, similar to that of the college control subjects, 12.7±0.4 years. Each year of training before menarche delayed menarche by five months (0.4 years). Of the premenarche-trained athletes, 61% had irregular menstrual cycles and 22% were amenorrheic, whereas 60% of the postmenarche-trained athletes had regular menstrual cycles and none were amenorrheic. Training increased the incidence of oligomenorrhea and amenorrhea among both premenarche- and postmenarche-trained athletes. Metabolic and hormonal changes consequent to an increased lean/fat ratio may explain these findings. (JAMA1981;246:1559-1563)

439 citations


Journal ArticleDOI
13 Nov 1981-JAMA
TL;DR: In 334 consecutive admissions for acute stroke, the blood pressure was elevated in 84% on the day of admission and decreased spontaneously an average of 20mm Hg systolic and 10 mm Hg diastolic in the ten days following the acute event.
Abstract: In 334 consecutive admissions for acute stroke, the blood pressure was elevated in 84% on the day of admission. The blood pressure decreased spontaneously an average of 20 mm Hg systolic and 10 mm Hg diastolic in the ten days following the acute event without specific antihypertensive therapy and was elevated in only one third of the cases on the tenth hospital day. The early elevation in blood pressure is likely a physiological response to brain ischemia, and blood pressure falls as recovery of brain function occurs. (JAMA1981;246:2177-2180)

433 citations


Journal ArticleDOI
02 Jan 1981-JAMA
TL;DR: There was a high correlation between low T4 levels and mortality and Hypothyroxinemia with normal thyroid-stimulating hormone levels was found in 22% of the patients.
Abstract: Thyroid function was measured in 86 patients hospitalized in an intensive care unit. Two patients were found to have primary hypothyroidism and were excluded from the study. Hypothyroxinemia with normal thyroid-stimulating hormone (TSH) levels was found in 22% of the patients and was associated with a high mortality (thyroxine [T4] levels less than 3.0 micrograms/dL, 84% mortality; T4 levels of 30 to 5.0 micrograms/dL, 50% mortality; and T4 levels greater than 5.0 micrograms/dL, 15% mortality). There was a high correlation between low T4 levels and mortality.

304 citations


Journal ArticleDOI
10 Apr 1981-JAMA
TL;DR: Carotid bruit was routinely sought in the Framingham cohort and during eight years appeared in 66 men and 105 women, all of whom were asymptomatic, and was clearly an indicator of increased stroke risk but chiefly as a general and nonfocal sign of advanced atherosclerotic disease.
Abstract: Carotid bruit was routinely sought in the Framingham cohort and during eight years appeared in 66 men and 105 women, all of whom were asymptomatic. The incidence increased with age equally in the two sexes from 3.5% at 44 to 54 years, to 7.0% at 65 to 79 years. The eight-year incidence was greater in diabetics and hypertensive subjects. Transient ischemic attacks appeared in eight (two alone) and stroke in 21 of the 171, a stroke rate more than twice expected for age and sex. More often than not, cerebral infarction occurred in a vascular territory different from that of the carotid bruit, often in the posterior circulation, and ruptured aneurysm, embolism from the heart, and lacunar infarction was the mechanism of stroke in nearly half the cases. Incidence of myocardial infarction was also increased twofold in those with asymptomatic carotid bruit. General mortality was also increased; 1.7-fold in men, and 1.9-fold in women, with 79% of the deaths owing to cardiovascular disease, including stroke. Carotid bruit is clearly an indicator of increased stroke risk but chiefly as a general and nonfocal sign of advanced atherosclerotic disease and not necessarily as an indicator of local arterial stenosis preceding cerebral infarction. ( JAMA 1981;245:1442-1445)

297 citations


Journal ArticleDOI
06 Mar 1981-JAMA
TL;DR: Patients younger than 16 years without nephritis have an excellent prognosis, and improved survival of this series may reflect closer follow-up, better nutritional status, and treatment at earlier stages of disease.
Abstract: Six hundred nine private patients with systemic lupus erythematosus were followed up for a mean of ten years. Ninety percent were female; 79% were white. Three hundred sixty-nine received diagnosis before 1970, and 234 after. Three hundred seventy-nine did not have nephritis; 230 did. The overall ten-year survival was 79% (87% without nephritis, 65% with nephritis). Male patients did consistently worse than female patients. No overall white vs nonwhite difference was noted. The presence of nephrotic syndrome at the onset of nephritis was a poor prognostic sign, but its development later was not. Patients younger than 16 years without nephritis have an excellent prognosis. One hundred twenty-eight patients died (82 with nephritis, 46 without nephritis). The most common causes of death were renal disease and sepsis. Improved survival of this series may reflect closer follow-up, better nutritional status, and treatment at earlier stages of disease. (JAMA1981;245:934-938)

294 citations


Journal ArticleDOI
16 Jan 1981-JAMA
TL;DR: Serum cholesterol level was inversely associated with incidence of colon cancer and with other sites only in men; these inverse associations were statistically significant after adjustment for age, alcohol consumption, cigarette smoking, education, systolic blood pressure, and relative weight.
Abstract: In 5,209 subjects studied for 24 years in Framingham, Mass, 691 cases of cancer were documented, with histological confirmation for 94%. Predetermined personal characteristics were tested for associations with subsequent occurrence of cancer at specific sites using multiple logistic regression. Significant associations of various cancer sites with cigarette smoking, alcohol use, education, height, weight, and parity agreed with other studies. Serum cholesterol level was inversely associated with incidence of colon cancer and with other sites only in men; these inverse associations were statistically significant after adjustment for age, alcohol consumption, cigarette smoking, education, systolic blood pressure, and relative weight. Associations may reflect effects of competing lethal diseases, underlying pathophysiological mechanisms that promote or inhibit development of cancer in men, biologic or social response to early and undiagnosed states of cancer. ( JAMA 1981;245:247-252)

292 citations


Journal ArticleDOI
01 May 1981-JAMA
TL;DR: The data suggest the menopausal flushes are associated with a chronic sleep disturbance, and both can be improved by estrogen therapy.
Abstract: To examine the possible relationship between the occurrence of menopausal hot flushes and waking episodes, a study was conducted of nine postmenopausal women with severe hot flushes and five asymptomatic premenopausal women. Measurement of simultaneous changes of finger temperature and skin resistance over the sternum was used as an objective marker of hot flushes. During cumulative sleep 47 objectively measured hot flushes occurred, and 45 were associated with a waking episode measured by polygraphic techniques. In eight of nine subjects, a significant correlation was observed between the occurrence of hot flushes and waking episodes. A similar association was not observed in premenopausal subjects. Estrogen administered to symptomatic patients resulted in significant reductions of both hot flushes and waking episodes. These data suggest that menopausal flushes are associated with a chronic sleep disturbance, and both can be improved by estrogen therapy. (JAMA1981;245:1741-1744)

288 citations


Journal ArticleDOI
06 Feb 1981-JAMA
TL;DR: During the last 30 years, epidemiologists have made remarkable progress in identifying important factors that are associated with the incidence of chronic diseases, and nowhere has this been more successful than in the area of coronary heart disease.
Abstract: During the last 30 years, epidemiologists have made remarkable progress in identifying important factors that are associated with the incidence of chronic diseases. Nowhere has this been more successful than in the area of coronary heart disease. Beginning with Professor Keys' study of Minnesota businessmen and the Framingham (Mass) Heart Study, innumerable reports have appeared that have documented a wide variety of personal characteristics strongly associated with heart attacks. These characteristics include high blood pressure, elevated blood cholesterol levels, cigarette smoking, and glucose intolerance. The available data for other characteristics are more controversial; these include overweight and obesity, physical activity, and specific components of diet. Most studies have been concerned with single population groups, and most of the reports have covered only one or two endpoints, usually coronary heart disease or myocardial infarction. However, a few studies have wisely examined several diverse population groups and have included the observation of

Journal ArticleDOI
07 Aug 1981-JAMA
TL;DR: Calculation of corrected efficacy predicts that, at an exclusion level equivalent to 2.25 SDs above the mean log for normal subjects, ALT testing of donors could prevent 29% of posttransfusion hepatitis at the loss of 1.6% of donor units.
Abstract: To assess the relationship of donor alanine aminotransferase (ALT) level to recipient hepatitis, 283 transfused patients were prospectively followed up after open heart surgery; hepatitis developed in 12.7%, of which 97% was non-A, non-B. The ALT tests on 3,359 donors to these patients indicated that risk of hepatitis was significantly associated with the level of donor ALT; 29% of 52 patients receiving at least 1 unit of blood with an ALT level greater than 53 IU/L had hepatitis develop (20.7 cases per 1,000 units), compared with 9% of 231 recipients of only blood with an ALT level of 53 IU/L or less (7.8 cases per 1,000 units). Calculation of corrected efficacy predicts that, at an exclusion level equivalent to 2.25 SDs above the mean log for normal subjects, ALT testing of donors could prevent 29% of posttransfusion hepatitis at the loss of 1.6% of donor units. ( JAMA 1981;246:630-634)

Journal ArticleDOI
08 May 1981-JAMA
TL;DR: Comparison of the two groups indicated that patients who received manipulative treatment were much more likely to report immediate relief after the first treatment, and at discharge, there was no significant difference between theTwo groups because both showed substantial improvement.
Abstract: A randomized clinical trial of rotational manipulation was conducted on 95 patients with low back pain selected for (1) the absence of any contraindications for vertebral manipulation, (2) the absence of any psychosocial problems that might affect the outcome of treatment, (3) the absence of any previous experience with manipulative therapy, and (4) the presence of palpatory cues indicating that manipulation might be successful. Patients were randomly assigned to one of two groups: an experimental group receiving manipulation therapy and a control group receiving soft-tissue massage. Comparison of the two groups indicated that (1) patients who received manipulative treatment were much more likely to report immediate relief after the first treatment, and (2) at discharge, there was no significant difference between the two groups because both showed substantial improvement. ( JAMA 1981;245:1835-1838)

Journal ArticleDOI
13 Nov 1981-JAMA
TL;DR: Although educational programs have had mixed success, those using individualized instruction have been most effective and alterations in the current reimbursement system could offer financial incentives to physicians who practice in a cost-effective manner.
Abstract: The important role of physicians in the generation of medical care costs is evident, but methods of inducing physicians to participate in cost-containment efforts are not well developed. Efforts to change physicians' use of medical services have included education, peer review and feedback, administrative changes, participation, penalties, and rewards. Although educational programs have had mixed success, those using individualized instruction have been most effective. Several feedback and peer-review programs have demonstrated reductions in costs, as have administrative interventions. While penalties and direct rewards may be effective, alterations in the current reimbursement system could offer financial incentives to physicians who practice in a cost-effective manner. ( JAMA 1981;246:2195-2201)

Journal ArticleDOI
17 Jul 1981-JAMA
TL;DR: To investigate the prevalence of acute psychological disturbances during the 24 hours preceding life-threatening ventricular arrhythmias, this work studied the mental states and psychological experiences preceding arrhythmic episodes in 117 patients who were referred for antiarrhythmmic management.
Abstract: To investigate the prevalence of acute psychological disturbances during the 24 hours preceding life-threatening ventricular arrhythmias, we studied the mental states and psychological experiences preceding arrhythmic episodes in 117 patients who were referred for antiarrhythmic management. Sixty-two had survived cardiac arrest and 55 suffered symptomatic ventricular tachycardia. Twenty-five patients were experiencing acute emotional disturbances during the 24 hours preceding the arrhythmias. Eighteen had two or more episodes associated with psychological disturbances. These 25 patients were distinguished from the rest of the series in having generally less severe structural heart disease. ( JAMA 1981;246:233-235)

Journal ArticleDOI
09 Jan 1981-JAMA
TL;DR: A study in over 115 hospitals in five metropolitan areas showed that males with pancreatic cancer were more often employed in the dry cleaning business or in occupations involving close exposure to gasoline as discussed by the authors.
Abstract: In the past 30 years, the incidence of pancreatic cancer has increased substantially. The disease now causes more deaths than all other malignant neoplasms, except those of the colorectal region, lung, and breast. A study in over 115 hospitals in five metropolitan areas showed that males with pancreatic cancer were more often employed in the dry cleaning business or in occupations involving close exposure to gasoline, increasing the risk for pancreatic cancer up to five times. Females at risk for pancreatic cancer were more likely to smoke cigarettes, to have uterine myomas, and to have undergone oophorectomy or spontaneous abortions. Generally, these patients were of higher social class and drank more wine and decaffeinated coffee than demographically similar controls. Assessment of the effects of several factors showed that relative risks increased 34-fold among females and nearly sixfold among males. While no single factor accounts for the preponderance of pancreatic cancer, a combination of factors—each associated with a relatively small risk enhancement—may very well do so. (JAMA1981;245:147-152)

Journal ArticleDOI
07 Aug 1981-JAMA
TL;DR: Alcohol abuse appears to be a risk factor in adverse fetal outcome, and excessive consumption has been implicated in impotency and early onset of postmenopausal amenorrhea.
Abstract: Ethanol is a drug that is classified as a general CNS depressant. Long-term exposure can result in tolerance and physical dependence. Ethanol consumption can affect the pharmacologic and therapeutic actions of prescription drugs, over-the-counter drugs, and illicit drugs. Ethanol-drug interactions have been reported to be the most frequent cause of drug-related medical crises in the United States. Alcohol misuse has a pervasive and potentially detrimental effect on the body from its point of entry through the gastrointestinal tract, to related organs such as the liver and the pancreas. The liver is one of the organs most significantly damaged and physiologically deranged as a result of alcohol ingestion. The two most common hepatic complications of alcoholism are hepatitis and cirrhosis. Cirrhosis was the seventh most common cause of death in the United States in 1975. Alcohol abuse interacts with physiological and metabolic processes of digestion to contribute to nutrient deficiency. Alcohol abuse has been suggested as the most common cause of vitamin and trace element deficiency in adults in the United States. Alcohol-derived nutritional deficiencies result in suboptimal health and are contributory to such abnormalities as anemia, convulsions, small-bowel dysfunction, and overt disorders such as Wernicke's encephalopathy. Brain dysfunction has been estimated to be present in from 50% to 70% of detoxified alcoholics entering treatment. Abstracting and adaptive abilities of social drinkers who had consumed no alcohol for 24 hours at the time of testing were found to be negatively associated with the amount of alcohol normally consumed per drinking occasion. Alcohol consumption alters numerous functions of the endocrine system, and excessive consumption has been implicated in impotency and early onset of postmenopausal amenorrhea. Recent evidence suggests that alcoholism may be a multifactorial genetically influenced disorder. In addition to genetics, social and environmental influences play significant roles. There is an association between alcoholism and depression in both men and women. Alcoholics often have high levels of depression and alcohol itself can increase depression. A disproportionately high number of people with drinking problems commit suicide, and more than a third of suicides involve alcohol. A propensity for suicide is thought to be associated with certain alcohol-related conditions such as depression, anxiety, mood fluctuations, and deteriorated social integration. Alcoholism has been associated with a number of adverse effects on the cardiovascular system, including a specific cardiomyopathy, low mean cardiac output, and depressed myocardial contractility. The drinking of large amounts of alcohol is associated with significant increases in blood pressure. Noncardiac myopathy has also been related to alcohol consumption. Heavy drinking increases the risk of cancer developing in the tongue, mouth, oropharynx, hypopharynx, esophagus, larynx, and liver. In the United States, these sites represent 6.1% to 9.1% of all cancer in the white population and 11.3% to 12.5% in the black population. In the broadest scope, alcohol abuse appears to be a risk factor in adverse fetal outcome. Fetal alcohol syndrome (FAS) has been identified among some children of alcoholic women. Fetal alcohol syndrome is characterized by CNS dysfunction, growth deficiency, a specific cluster of facial abnormalities, and other malformations, particularly skeletal, urogenital, and cardiac. It has been suggested that FAS is one of the leading causes of birth defects associated with mental retardetion. Short of the full complement of defects that characterize FAS, heavy alcohol use by women has been associated with birth anomalies. These effects of alcohol are independent of likely confounding variables, including smoking. Decreased birth weight is frequently associated with increased neonatal risk and has been observed among the children of women who consume an average of 30 mL of absolute alcohol per day (two standard drinks). Teratogenesis has also been noted in studies using alcohol-consuming animal models in whom the human condition is mimicked. Laboratory experiments have found that alcohol significantly impairs performance on sensory-motor and cognitive tasks at blood alcohol levels as low as 40 mg/dL. Such acute alcohol effects may contribute to other health hazards that may require medical treatment. For example, one third of all traffic fatalities are alcohol related; a significant number of industrial accidents, drownings, burns, and falls have been attributed to drinking; and a relatively high involvement of alcohol has been reported in assault, rape, child abuse and neglect, child molestation, and family violence in general. ( JAMA 1981;246:648-666)

Journal ArticleDOI
15 May 1981-JAMA
TL;DR: It is suggested that a significant proportion of patients with depression and anergia may have early hypothyroidism, the cases of about half of which are detected only by thyrotropin-releasing hormone (TRH) testing.
Abstract: To evaluate the relationship between hypothyroidism and depression, thyroid function was evaluated in 250 consecutive patients referred to a psychiatric hospital for treatment of depression or anergia. Twenty of the 250 patients had some degree of hypothyroidism. Two patients (less than 1%) were identified with grade 1 (overt); nine patients (3.6%), grade 2 (mild); and ten patients (4%), grade 3 (subclinical) hypothyroidism. These results suggest that a significant proportion of patients with depression and anergia may have early hypothyroidism, the cases of about half of which are detected only by thyrotropin-releasing hormone (TRH) testing. Because hypothyroidism can produce signs and symptoms of depression and can coexist as a second illness in depressed patients, patients with early hypothyroidism may be candidates for thyroid replacement therapy. Clinical examination and measurement of triiodothyronine resin uptake thyroxine and baseline thyroid-stimulating hormone (TSH) levels, and TSH response to TRH are necessary to identify candidates for thyroid replacement among cases diagnosed by descriptive criteria as having either major or minor depression, particularly those that are atypical or treatment resistant. ( JAMA 1981;245:1919-1922)

Journal ArticleDOI
03 Apr 1981-JAMA
TL;DR: Data indicate that a proportion of men have gonadal dysfunction prior to treatment for Hodgkin's disease and subsequent chemotherapy, and it is clear that cytotoxic therapy induces infertility.
Abstract: Forty-seven men (median age, 31.5 years) were studied prospectively to assess the effect of Hodgkin's disease and subsequent chemotherapy on gonadal function. Before therapy, 16 (43%) of 37 men were functionally subfertile, as assessed by impotence (four of 37) and "inadequate" sperm counts (12 of 37). Histological abnormalities were noted in eight of nine pretreatment testicular biopsy specimens. Additionally, changes were noted in blood hormone levels and libido. After completion of only two cycles of chemotherapy, 14 of 14 men became persistently azoospermic, with blood follicle-stimulating hormone levels four to five times normal. Posttreatment testicular biopsy specimens confirmed germ cell aplasia. During therapy 17 (81%) of 21 men had mild or no libido; irritability in 16 (84%) of 19 and violence in four (18%) of 22 caused additional family distress. While it is clear that cytotoxic therapy induces infertility, these data further indicate that a proportion of men have gonadal dysfunction prior to treatment. ( JAMA 1981;245:1323-1328)

Journal ArticleDOI
17 Apr 1981-JAMA
TL;DR: In a cooperative study of 3,099 life insurance applicants with atrial fibrillation (AF), 71 deaths over an average duration of 3.3 years were observed and compared with deaths expected and derived from standard insurance mortality tables.
Abstract: In a cooperative study of 3,099 life insurance applicants with atrial fibrillation (AF), 71 deaths over an average duration of 3.3 years were observed and compared with deaths expected and derived from standard insurance mortality tables. A normal mortality was observed in cases of paroxysmal AF with no other identified cardiovascular impairment. Paroxysmal AF with associated mitral stenosis or coronary disease was found to have a significantly increased mortality. Chronic AF with or without other impairments entails a much higher risk than paroxysmal AF, those cases associated with mitral stenosis showing very high excess mortality. ( JAMA 1981;245:1540-1544)

Journal ArticleDOI
27 Feb 1981-JAMA
TL;DR: The results suggest that warfarin may be useful in the treatment of SCCL and also support the hypothesis that the blood coagulation mechanism may be involved in the growth and spread of cancer in man.
Abstract: In a controlled, randomized study, survival of patients with small cell carcinoma of the lung (SCCL) was prolonged on addition of warfarin sodium to combination chemotherapy plus radiation therapy. Median survival for 25 control patients was 24 weeks and for 25 warfarin-treated patients was 50 weeks. This difference could not be accounted for by differences between groups in performance status, extent of disease, age, or sex. The survival advantage associated with warfarin administration was observed both for patients with extensive disease and for those who failed to achieve complete or partial remission. The warfarin-treated group also demonstrated a significantly increased time to first evidence of disease progression. These results suggest that warfarin may be useful in the treatment of SCCL and also support the hypothesis that the blood coagulation mechanism may be involved in the growth and spread of cancer in man. ( JAMA 1981;245:831-835)

Journal ArticleDOI
14 Aug 1981-JAMA
TL;DR: Twenty-two women aged 13 to 44 years (mean, 22 years) with toxic shock syndrome were hospitalized in Madison, Wis, between Aug 1, 1977, and Sept 1, 1980; all recovered.
Abstract: Twenty-two women aged 13 to 44 years (mean, 22 years) with toxic shock syndrome (TSS) were hospitalized in Madison, Wis, between Aug 1, 1977, and Sept 1, 1980. Disease onset occurred during menses in 21 patients; all recovered. Notable sequelae included vocal cord paralysis and impaired finger sensation in two patients and recurrent disease in three. Coagulase-positive staphylococci were grown from the cervix or vagina in 11 of 12 women cultured. Previously undescribed features included vulvar cellulitis, hypocalcemia, hypophosphatemia, hypocholesterolemia, hyponatremia, lymphocytopenia, hypoferrinemia, and late convalescent hair and nail loss. Patients requiring dopamine hydrochloride had worse renal function, longer hospitalizations, and higher total serum bilirubin levels, and clinical onset earlier in menses. Originally reported in children, TSS now appears to be primarily a disease of menstruating women in whom recurrences are possible. (JAMA1981;246:741-748)

Journal ArticleDOI
02 Oct 1981-JAMA

Journal ArticleDOI
01 May 1981-JAMA
TL;DR: The nine steps in the performance of any laboratory test include ordering, collection, identification (at several stages), transportation, separation, separation (or preparation), analysis, reporting, interpretation, and action.
Abstract: The nine steps in the performance of any laboratory test include ordering, collection, identification (at several stages), transportation, separation (or preparation), analysis, reporting, interpretation, and action. 1 Unless the appropriate action occurs, it is as if the cycle had never begun and is, at the most, a tragedy and, at the least, a waste. Several years ago, we coined the phrase "brain-to-brain turnaround time" in which we envisioned a loop such as is shown in the Figure. Anything that interferes with closure of the loop through step 9 leaves an "open loop"—the bane of any decision or information system. 2 We have discovered over many years at several institutions that physicians "want what they want when they want it" and that anything that stands in the way of their prompt and perfect receiving of laboratory results for their patients is perceived as a "laboratory problem or error." Thus, matching responsibility,

Journal ArticleDOI
28 Aug 1981-JAMA
TL;DR: The major role of anaerobic organisms in the polymicrobial cause of long-term sinusitis in children is indicated and indicated by aseptically performing aspiration of chronically inflamed sinuses.
Abstract: Aspiration of chronically inflamed sinuses was aseptically performed in 40 children. The median age was 11 years (range, 6 to 16 years). The sinuses were the maxillary (15 cases), ethmoid (13), and frontal (seven). Pansinusitis was present in five patients. All aspirates were cultured for aerobes and anaerobes and yielded bacterial growth in 37 patients. A total of 121 isolates (97 anaerobic and 24 aerobic) were recovered, accounting for 2.7 anaerobes and 0.6 aerobes per specimen. Anaerobic organisms were recovered from all 37 culture-positive specimens, and in 14 cases (38%) they were mixed with aerobic organisms. The predominant anaerobic organisms were Bacteroides species (36), anaerobic Gram-positive cocci (28), and Fusobacterium species (13). The predominant aerobic isolates were α-hemolytic streptococci (seven), Staphylococcus aureus (seven), and Haemophilus species (four). These findings indicate the major role of anaerobic organisms in the polymicrobial cause of long-term sinusitis in children. ( JAMA 1981;246:967-969)

Journal ArticleDOI
22 May 1981-JAMA
TL;DR: The total number of lifetime donations was not as predictive of decreased iron stores as frequency of donations per year, and even casual iron supplementation reduced the impact of donations on iron stores.
Abstract: A high frequency of donations by some blood donors has prompted concern about iron depletion. Five hundred sixteen female and 505 male donors were examined by measurements of hemoglobin, hematocrit, plasma iron, total iron-binding capacity, and ferritin values and detailed histories of iron ingestion, pregnancy and menstrual status, and past blood donations. Hemoglobin, hematocrit, and serum iron studies, unlike ferritin values, were not sensitive indicators of body iron depletion. Reduced iron stores were found in 8% of male and 23% of female donors. Menstruation significantly lowered iron stores in women. The total number of lifetime donations was not as predictive of decreased iron stores as frequency of donations per year. Even casual iron supplementation reduced the impact of donations on iron stores. Administration of iron to donors, especially menstruating women, should be studied by blood programs. ( JAMA 1981;245:2038-2043)

Journal ArticleDOI
13 Nov 1981-JAMA
TL;DR: This report is a summary of currently accepted medical practices for the determination of death, both cardiorespiratory and neurological, although the majority of the report is devoted to the diagnosis of neurological, or brain, death.
Abstract: The report on "Guidelines for the Determination of Death" in this issue (p 2184) is a landmark document with far-reaching medical, ethical, and legal implications. It is a summary of currently accepted medical practices for the determination of death, both cardiorespiratory and neurological, although the majority of the report is devoted to the diagnosis of neurological, or brain, death. Physicians from numerous specialities contributed to the drafting of this report, which was coordinated by the staff of the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. These guidelines are included as an appendix to the more comprehensive report by the President's Commission on "Defining Death: A Report on the Medical, Legal and Ethical Issues in the Determination of Death" (this entire report was approved by the President's Commission and sent to the President on July 9, 1981). Until now, the most widely accepted

Journal ArticleDOI
06 Feb 1981-JAMA
TL;DR: A statistically insignificant decrease in the rate of brain metastasis was found among irradiated patients with small cell carcinoma, and prophylactic cranial irradiation can decrease morbidity from non-small-cell carcinoma of the lung.
Abstract: The Veterans Administration Lung Group conducted a prospective study of irradiation for subclinical brain metastases in patients with inoperable carcinoma of the lung between 1975 and 1978. Patients were randomized to receive whole-brain irradiation (2,000 rads in two weeks) or no brain treatment, and to receive one of two regimens of thoracic irradiation. Three hundred twenty-three patients with normal radionuclide brain scans were able to be evaluated. The rate of clinical brain metastasis was 26% for patients with small cell carcinoma vs 10% for the "non-small-cell" group. A statistically insignificant decrease in the rate of brain metastasis was found among irradiated patients with small cell carcinoma. The frequency of brain metastasis in the non-small-cell patients was reduced from 13% to 6% by irradiation. Prophylactic cranial irradiation can decrease morbidity from non-small-cell carcinoma of the lung. ( JAMA 1981;245:469-472)

Journal ArticleDOI
16 Oct 1981-JAMA
TL;DR: The data support the current recommendation for ten full days of penicillin therapy and suggest that persistence of streptococci in the throat after adequate therapy may be common.
Abstract: The effect of duration of orally administered penicillin V potassium on the bacteriologic and clinical cure of group A streptococcal pharyngitis was evaluated. One hundred ninety-one middle-class patients received either seven days (96 patients) or ten days (95 patients) of therapy. Compliance with taking penicillin was assessed by multiple methods, including penicillinuria. Throat cultures were obtained during therapy and three times in the three weeks after therapy. M-precipitin and T-agglutinin typing were done on paired isolates of group A streptococci from patients who had recurrences. Patients treated for seven days had a significantly greater failure rate (30/96 [31%]) compared with patients receiving ten days of penicillin (17/95 [18%]). Compliance rates were high; 66% to 81% of patients showed penicillinuria throughout the study period. Treatment failure was not a function of poor compliance in either treatment group. The data support the current recommendation for ten full days of penicillin therapy and suggest that persistence of streptococci in the throat after adequate therapy may be common.

Journal ArticleDOI
13 Nov 1981-JAMA
TL;DR: Patients who received internal mammary artery (IMA) grafts were reviewed seven to nine years after surgery; 91.6% of these patients are still alive and there was little, if any, evidence of atherosclerosis in the IMAs.
Abstract: Two hundred ninety-eight patients who received internal mammary artery (IMA) grafts were reviewed seven to nine years after surgery; 91.6% of these patients are still alive. In 29.5% of these patients there was postoperative graft visualization, and 90% of the studies were performed because of suspected graft failure. Attrition of the IMA graft was minimal. At zero to 24 months after surgery, 93.4% of grafts were patent. At 60 to 108 months 94.4% were patent and there was little, if any, evidence of atherosclerosis in the IMAs. Precise technique in preparation and anastomosis of the IMA is essential for long-term patency. For bypassing obstructive lesions, we recommend selection of the IMA (if it has sufficient size and flow) for use in the left anterior descending, large diagonal, or marginal vessel in the left coronary artery circulation. ( JAMA 1981;246:2181-2183)