Showing papers in "JAMA in 1984"

Detecting alcoholism. The CAGE questionnaire.

Abstract: Four clinical interview questions, the CAGE questions, have proved useful in helping to make a diagnosis of alcoholism. The questions focus on Cutting down, Annoyance by criticism, Guilty feeling, and Eye-openers. The acronym "CAGE" helps the physician to recall the questions. How these questions were identified and their use in clinical and research studies are described.

Lipid Research Clinics Program

Abstract: To the Editor.— The article by the Lipid Research Clinics Program 1 on reduction in instances of coronary artery disease was a very useful study for the physician interested in primary prevention of coronary artery disease. I have had relatively poor success keeping patients on a regimen of cholestyramine in my own practice because of the cost. The least expensive form of cholestyramine resin available through a local pharmacy would cost my patient $31.20 a week to take 24 g/day. This comes to a total cost of $1,622.40 a year. If, as the study suggests, there are 1 1/2 million Americans who would qualify for this form of therapy, the cost considerations become impressive. Some simple arithmetic demonstrates that the cost nationwide for each patient spared a cardiac end point is $715,764.70. Who says that coronary artery surgery is expensive?

Do Patients Want to Participate in Medical Decision Making

Abstract: Although shared decision making by patients and clinicians has been advocated, little is known about the degree of participation in decision making that patients actually prefer or about clinicians' appreciation of these preferences. We administered questionnaires about three aspects of decision making to 210 hypertensive outpatients and to their 50 clinicians, who represented three types of medical practices. We found that 41% of patients preferred more information about hypertension; clinicians underestimated patient preferences for discussion about therapy in 29% of cases and overestimated in 11% (K=.22); and 53% of patients preferred to participate in making decisions, while clinicians believed that their patients desired to participate in 78% of cases. Many patients who preferred not to make initial therapeutic decisions did want to participate in ongoing evaluation of therapy. Thus, clinicians underestimate patients' desire for information and discussion but overestimate patients' desire to make decisions. Awareness of this discrepancy may facilitate communication and decision making. ( JAMA 1984;252:2990-2994)

Clinical Guide to Laboratory Tests

Abstract: The Clinical Guide to Laboratory Tests potentially provides valuable information in a condensed format, especially for the house officer or nurse needing a quick reference. Despite these advantages, it is a difficult book to review, particularly because its very strengths in presenting large amounts of information result in weaknesses. For example, explanations on serum glucose measurements and the glucose tolerance test are as complete as expected, including references from the National Diabetes Data Group. Conversely, descriptions of the sweat chloride test include only a mention of reference values established at the University of Kentucky Medical Center, Lexington, and a questionable comment on possible false-negative results caused by "excessive sweating during hot weather." In addition, there is no reference to the Cystic Fibrosis Report ( J Pediatr 1976; 88(II):711-750) or a similar report that might provide an authoritative source of information. Unfortunately many other test discussions also cite only textbooks or locally

Evolution of Language

Abstract: To the Editor.— The article entitled "The Dominance of Scientific English" by Robertson and Robertson 1 is of interest. The plea for a single scientific English may be a good one, but each "language" developed by a process more complicated than a simple "split," as is generally the case, and languages once "split" scarcely ever reunite. The one standard scientific English will never be a reality. In fact, the problem may be how long the standard American English will remain "standard." It is being observed in our American educational system that fewer and fewer people learn to read at an advanced level. Many reasons are given, but rarely or never discussed is the simple fact that people throughout history have generally had a hankering for reading their spoken language and an aversion for reading foreign languages, including dialects that are not their spoken dialect. As painful as it may be

Toxoplasmic encephalitis in patients with acquired immune deficiency syndrome.

Abstract: An epidemic of cases of toxoplasmic encephalitis is occurring in patients with acquired immune deficiency syndrome (AIDS). Serological or histopathologic studies were performed on 70 cases with AIDS and toxoplasmic encephalitis. In many cases conventional stains of brain-tissue specimens failed to disclose Toxoplasma organisms; all were positive when stained by the peroxidase-antiperoxidase technique. Except for a single patient, serological titers were not indicative of an acute acquired infection. The ratio of titers in the agglutination test to titers in the Sabin-Feldman dye test seemed to be more predictive of active toxoplasmic encephalitis in patients with AIDS than either test alone. Based on histological and serological data, an approach is presented for diagnosis and treatment of suspected toxoplasmic encephalitis in patients with AIDS. ( JAMA 1984;252:913-917)

Physical fitness and incidence of hypertension in healthy normotensive men and women.

Abstract: We measured physical fitness, assessed by maximal treadmill testing in 4,820 men and 1,219 women aged 20 to 65 years. Participants had no history of cardiovascular disease and were normotensive at baseline. We followed up these persons for one to 12 years (median, four years) for the development of hypertension. Multiple logistic risk analysis was used to estimate the independent contribution of physical fitness to risk of becoming hypertensive. After adjustment for sex, age, follow-up interval, baseline blood pressure, and baseline body-mass index, persons with low levels of physical fitness (72% of the group) had a relative risk of 1.52 for the development of hypertension when compared with highly fit persons. Risk of hypertension developing also increased substantially with increased baseline blood pressure. ( JAMA 1984;252:487-490)

Migration and granulomatous reaction after periurethral injection of polytef (Teflon).

Abstract: Although patients with urinary incontinence have been treated successfully by periurethral injection of polytef paste, this study in continent animals demonstrates migration of polytef particles from the injection site. We injected polytef paste periurethrally into female dogs and male monkeys. Particles were found at 50 to 70 days in pelvic nodes in six of seven animals and lungs in four of seven (the kidneys and brain were not studied); and at 10 1/2 months in pelvic nodes, lungs, and brain in seven of seven; kidneys in four of seven; and spleen in two of seven. X-ray microanalysis confirmed that the particles were polytef. At 10% months, polytef granulomas were found at all injection sites and some sites of distant migration. Since these granulomas signify chronic foreign-body reaction, we believe that until the long-term effects in humans are known, polytef paste should not be used in children or young adults with normal life expectancy. (JAMA1984;251:3277-3281)

Efficacy of Methylprednisolone in Acute Spinal Cord Injury

Abstract: A multicenter double-blind randomized trial was conducted to examine the efficacy of a high dose of methylprednisolone (1,000-mg bolus and daily thereafter for ten days) compared with a standard dose (100-mg bolus and daily thereafter for ten days) in 330 patients with acute spinal cord injury. No difference in neurological recovery of motor function or pinprick and light touch sensation was observed between the two treatment groups six weeks and six months after injury. The lack of a treatment effect was independent of the severity of the initial lesion or the time from injury to starting treatment. Although not statistically significant, early case fatality was greater in the high-dose protocol (relative risk of 3.1 and 1.9, ≤ 14 and 15 to 28 days after injury, respectively) but not from 29 to 210 days after injury. Wound infections of both trauma and operative sites were more prevalent in the high-dose regimen (relative risk of 3.6). (JAMA1984;251:45-52)

Doctor-patient communication. Clinical implications of social scientific research.

Abstract: Research in the social sciences has clarified the nature and problems of doctor-patient communication. The development of adequate communication skills is now a goal of training programs in the primary-care specialties. Social structural barriers impede effective communication, however, and information giving remains problematic. Doctors tend to underestimate patients' desire for information and to misperceive the process of information giving. The transmission of information is related to characteristics of patients (sex, education, social class, and prognosis), doctors (social-class background, income, and perception of patients' desire for information), and the clinical situation (number of patients seen). Doctors' nonverbal communication abilities are associated with outcomes of medical care such as satisfaction and compliance. Regarding the sociolinguistic structure of communication, doctors often maintain a style of high control, which involves many doctor-initiated questions, interruptions, and neglect of patients' "life world." Training programs and standards of clinical practice should emphasize that improved doctor-patient communication is both desirable and possible.

A Clinical Trial of Change in Maternal Smoking and Its Effect on Birth Weight

Abstract: These clinical trial results are the first, to our knowledge, from a prospective, randomized, and controlled experiment demonstrating that a reduction of smoking during pregnancy improves the birth weight of the infant. Nine hundred thirty-five pregnant smokers were randomly assigned to treatment and control groups; the former received smoking intervention. At the eighth month of pregnancy, differences between the two groups in salivary thiocyanate level and reported smoking were statistically significant. For single, live births, the treatment group infants had a mean birth weight that was 92 g heavier and were 0.6 cm greater in length than the control group infants. The decrement in weight related to smoking cannot be fully explained by gestational age. The findings suggest that some fetal growth retardation can be overcome by the provision of antismoking assistance to pregnant women. (JAMA1984;251:911-915)

Excessive intake of zinc impairs immune responses.

Abstract: The effect of administration of large amounts of zinc on immune response and serum lipoproteins was examined. Eleven healthy adult men ingested 150 mg of elemental zinc twice a day for six weeks. This was associated with a reduction in lymphocyte stimulation response to phytohemagglutinin as well as chemotaxis and phagocytosis of bacteria by polymorphonuclear leukocytes. Serum high-density lipoprotein concentration decreased significantly and low-density lipoprotein level increased slightly. The common food fad of zinc supplementation with resultant excessive intake could have deleterious effects in healthy persons. ( JAMA 1984;252:1443-1446)

Growth Hormone Neurosecretory Dysfunction: A Treatable Cause of Short Stature

Abstract: Pulsatile growth hormone (GH) secretion was assessed in a subgroup of short children to determine whether they had GH secretory abnormalities, and these results were compared with those of normal and GH-deficient children. This subgroup of children was defined as having GH neurosecretory dysfunction and met the following criteria: height, less than first percentile; growth velocity, 4 cm/yr or less; bone age, two or more years behind chronological age, normal findings from provocative GH tests (peak, ≥10 ng/mL), low somatomedin-C level, and abnormal 24-hour GH secretory patterns. When compared with controls, both children with GH neurosecretory dysfunction and GH-deficient patients had a significant decrease in parameters relating to the total GH secretion during the 24-hour period. As with GH-deficient children, the group with GH neurosecretory dysfunction more than doubled their growth velocity after replacement therapy with exogenous human GH during the first year of treatment. As a result of these detailed studies on pulsatile GH secretion, we suggest that there is a spectrum of GH secretory abnormalities from absolute deficiency to an intermittent irregularity in GH secretion. (JAMA1984;251:2223-2230)

Autopsy findings in the acquired immune deficiency syndrome.

Abstract: The medical records, premortem biopsy specimens, and autopsy materials from 36 patients with acquired immune deficiency syndrome (AIDS) were reviewed. The majority of the patients were homosexual men. Widely metastatic Kaposi's sarcoma was seen in eight patients, while tumor was confined to the skin in an additional ten. Four patients had high-grade lymphomas. Thirty-five of the 36 patients had at least one opportunistic infection at some point in the course of their illness. Many patients had multiple infectious agents. The most consistent and striking autopsy finding was a severe depletion of lymphoid tissues. Death in the majority (83%) of the patients was attributable to opportunistic infections affecting most commonly the respiratory tract (64%) and meninges (11%). Three patients (9%) died with widely metastatic Kaposi's sarcoma and secondary hemorrhage. ( JAMA 1984;252:1152-1159)

Herpesvirus infections in the acquired immune deficiency syndrome.

Abstract: Herpesvirus infections were studied in persons with or at risk for the acquired immune deficiency syndrome (AIDS). The infections diagnosed were as follows: patients with AIDS, cytomegalovirus (CMV) in 34 of 34, Epstein-Barr virus (EBV) in 33 of 34, herpes simplex viruses (HSV) in eight of 34, and varicella zoster virus in four of 34; patients with chronic lymphadenopathy syndrome, CMV in eight of nine and EBV in nine of nine; in healthy homosexual men, CMV in five of 13 and EBV in seven of eight. Cytomegalovirus infections were frequently related to disease and death. Herpesvirus infections are frequent causes of serious diseases in AIDS. The prevalence of EBV and CMV infections in AIDS and the chronic lymphadenopathy syndrome may be the result of an important interaction between these viruses and the cause of AIDS. ( JAMA 1984;252:72-77)

Staging of disease. A case-mix measurement.

Abstract: The development of techniques for the measurement of hospital output is one of the primary issues facing health service researchers. Scales must be developed which can be used to categorize patients in such a way that homogeneity within patient groups and heterogeneity between patient groups, with respect to the nature of their illness, is maximized. Such a categorization scheme, which must allow for the assessment of the severity of illness can then be used for studies of hospital utilization and costs; development of equitable reimbursement mechanisms for hospitals; and for clinical trails designed to test the efficacy of different treatment modalities.

Continuity of Outpatient Medical Care in Elderly Men: A Randomized Trial

Abstract: P6 an outpatient repeatedly sees the same practitioner, is his care influenced? This double-blind randomized trial examines the effects of outpatient health care provider continuity on the process and outcome of the medical care for 776 men aged 55 years and older. Participants were randomized to two different groups of provider care: provider discontinuity and provider continuity. The outcome of the continuity group was significantly different from that of the discontinuity group. During an 18-month period, patients who had been randomized to the continuity group had fewer emergent admissions (20% v 39%) and a shorter average length of stay (15.5 v 25.5 days). These patients also perceived that the providers were more knowledgeable, thorough, and interested in patient education. We conclude that continuity of outpatient provider care for men aged 55 years and older results in more patient satisfaction, shorter hospitalizations, and fewer emergent hospital admissions.

Decreased Spinal Mineral Content in Amenorrheic Women

Abstract: Premenopausal amenorrheic women may be at risk for the development of osteoporosis. In hyperprolactinemia, cortical bone mass is decreased and the magnitude of the decrease correlates with the severity of the estrogen deficiency. However, bone loss in women with amenorrhea from other causes has not been assessed. We have studied women with hypothalamic and hyperprolactinemic amenorrhea and premature ovarian failure. Bone mass in the peripheral cortical bone was only slightly decreased from age-matched controls, but spinal trabecular bone was decreased 20% to 30%. Estradiol levels were 20 to 80 pg/mL in these women, not different from normal early follicular levels. The decrease in bone mass in the spine did not correlate with serum estradiol at these levels. The hypothalamic amenorrhea group was made up of athletes in whom the bone mass decrease was an unexpected finding. ( JAMA 1984;251:626-629)

A Natural History of Athleticism and Cardiovascular Health

Abstract: Epidemiologic studies in Olympic year 1984 suggest that personal athleticism alters trends in life-style and coronary heart disease. Analysis of 572 first attacks among 16,936 Harvard alumni, 1962 to 1972, and 1,413 total deaths, 1962 to 1978, shows that habitual postcollege exercise, not student sports play, predicts low coronary heart disease risk. Sedentary alumni, even ex-varsity athletes, have high risk. Sedentary students becoming physically active alumni acquire low risk. Exercise benefit is independent of contrary life-style elements—smoking, obesity, weight gain, hypertension, and adverse parental disease history—in affecting coronary heart disease incidence. Hypertension is clinically the strongest predictor of coronary attack, but inadequate exercise is strongest on a community basis. Exercise level is inversely related to total, cardiovascular, and respiratory mortality but less related to cancer or unnatural deaths. The current exercise revolution may improve life-style, cardiovascular health, and longevity. ( JAMA 1984;252:491-495)

The second impact in catastrophic contact-sports head trauma.

Abstract: CATASTROPHIC brain injury following minor impact has been known to occur in contact sports, particularly football. 1 This peculiar susceptibility remains unexplained. However, the common resumption of contact play soon after concussion suggests that sequential minor impacts may occasionally lead to major cerebral pathological conditions. If these injuries have a compounding effect rather than representing isolated events, then additional impact to an already compliance-compromised brain might precipitate a catastrophic increase in intracranial pressure, perhaps through loss of vasomotor tone. We report a case documenting a preexisting cerebral contusion and the lethal effect of a second minor impact. This case suggests that clinical examination alone may sometimes be inadequate in evaluating persisting symptoms after minor head injury. In the athlete who has had a cerebral concussion, computed tomographic (CT) scanning may be required before medical clearance to resume play is justified. Report of a Case A 19-year-old, right-handed, college football player

Long-term Outcome of Episodes of Major Depression: Clinical and Public Health Significance

Abstract: Twenty-one percent (20/97) of patients with an episode of major depressive disorder and no history of chronic minor depression who sought treatment at five university medical centers had not recovered after two years of prospective follow-up The rate of recovery was highest in the three months after entry into the study, with a notable decrease in rate after one year Most patients who did not recover had severe depressive symptoms throughout the two years of follow-up Long duration of episode before entry into the study, inpatient hospitalization status at entry, intact marriage, low family income, admitting research center, and a history of nonaffective psychiatric disorders (including alcoholism) predicted a chronic course The implications of these findings for clinicians, researchers, and public health planners are discussed ( JAMA 1984;252:788-792)

A Critical Appraisal of the Efficacy of Continuing Medical Education

Abstract: To determine the efficacy of continuing medical education (CME), we collected 248 original articles describing studies of CME interventions. These articles were reviewed for applicability and scientific credibility by applying preset methodological criteria. Thirteen percent of articles described randomized trials, but only 7% of all articles and 20% of randomized trials assessed the impact of CME on patient outcomes. Seven articles met all our criteria and were reviewed in detail. These studies provide convincing evidence that CME can improve physician behaviors. However, only three of these methodologically sound studies assessed patient outcomes and only one demonstrated any improvement in outcomes. ( JAMA 1984;251:61-64)

Do Physicians Preach What They Practice?: A Study of Physicians' Health Habits and Counseling Practices

Abstract: We examined the relation of physicians' clinical specialty, personal health habits, and health-related beliefs to their practices in counseling about smoking, weight, exercise, and alcohol. We surveyed a random sample of members of a county medical society in selected specialties. Physicians with better personal health habits and more positive attitudes toward counseling counsel a broader range of patients and counsel more aggressively. Surgeons counsel less than nonsurgeons, even after controlling for differences in health-related attitudes and personal habits. ( JAMA 1984;252:2846-2848)

B-cell immunodeficiency in acquired immune deficiency syndrome.

Abstract: To investigate B-cell function in acquired immune deficiency syndrome (AIDS), we immunized a group of patients with AIDS with pneumococcal polysaccharide (tetradecavalent) and protein (keyhole-limpet hemocyanin) antigens. Antibody responses were determined three to four weeks after immunization. Compared with controls, patients with AIDS had significantly lower geometric mean antibody levels to polysaccharide before and after immunization. Levels before and after immunization were frequently below a level thought to correlate with protection. Patients with AIDS also had a significant reduction in their primary antibody response to the protein antigens. The results of these studies indicate that AIDS is associated with an acquired B-cell as well as T-cell immunodeficiency. It is suggested that future studies should consider the evaluation of passive antibody in the prevention of infection and/or prevention of progressive immunodeficiency. (JAMA1984;251:1447-1449)

Competency to give an informed consent. A model for making clinical assessments.

Abstract: A patient's decision must be informed and free, and he/she must be competent either to consent to or refuse treatment. Rather than selecting a single standard of competency, a sliding scale is suggested that requires an increasingly more stringent standard as the consequences of the patient's decision embody more risk. The standard of competency to consent to or to refuse treatment depends on the dangerousness of the treatment decision. Three different standards are correlated with the psychiatric abnormalities that are most likely to undermine them. A model with guidelines for use is provided to aid the physician who is called on to make a determination of competency.

Treatment of Recurrent Genital Herpes Simplex Infections With Oral Acyclovir: A Controlled Trial

Abstract: Two hundred fifty patients were entered into a multicenter trial to evaluate the efficacy and toxicity of orally administered acyclovir for treatment of recurrent genital herpes. The study consisted of part A, in which patients entered the study within 48 hours of the onset of lesions, and part B, in which patients self-initiated therapy as soon as possible after the onset of a recurrent episode. In both parts, patients received either acyclovir (200 mg) or placebo, five times daily for five days. In both parts, the duration of virus shedding and the time to crusting and healing of lesions were shorter among acyclovir recipients than among placebo recipients. In part B, fewer acyclovir recipients formed new lesions during the study medication period than did placebo recipients. When parts A and B were compared directly, the duration of virus shedding and the times required for crusting and healing of lesions were significantly shorter among acyclovir recipients in part B than among acyclovir recipients in part A. No significant differences in the duration of itching and pain or in the times of subsequent recurrence were noted between acyclovir and placebo groups in either part A or part B. No significant toxic or adverse reactions were seen in acyclovir recipients. Oral acyclovir shortens the duration of virus shedding and the duration of lesions in patients with recurrent genital herpes. These effects are more pronounced when therapy is self-initiated by patients early in the course of a recurrent episode.

Predictive value of urodynamic evaluation in newborns with myelodysplasia

Abstract: We examined 36 infants with myelodysplasia, using excretory urography, voiding cystourethrography, and urodynamic assessment in the newborn period and periodically thereafter to determine those at risk for decompensation of the urinary tract. Urodynamic evaluation showed 18 with dyssynergia of the detrusor and external sphincter, nine with synergic activity of the sphincter, and nine with no activity of the sphincter. Thirteen (72%) of the group with dyssynergia had or later were found to have hydroureteronephrosis, while this was the case in only two (22%) with synergy and one (11%) with absent activity. The conditions of these 16 patients improved after decompression by cutaneous vesicostomy or intermittent catheterization. Infants with dyssynergia of the detrusor-external sphincter are at high risk for deterioration of the urinary tract; they should be followed up closely, and intermittent catheterization should be started early. ( JAMA 1984;252:650-652)

Reduced serum testosterone and prolactin levels in male distance runners.

Abstract: To investigate whether endurance running in men produced basal hormonal changes similar to those reported in women, we obtained blood samples from 31 men running at least 64 km each week and 18 sedentary controls for measurement of levels of total testosterone, non-sex hormone-binding globulin-bound and free testosterone, luteinizing hormone, follicle-stimulating hormone, prolactin, and cortisol. The mean levels of total and nonspecifically bound testosterone as well as prolactin were significantly lower than in controls, although levels remained within the physiological range. Other hormone levels were similar in both groups. The lowered testosterone and prolactin levels parallel the changes reported in women runners. (JAMA1984;252:514-516)

Effects of Endurance Training on Glucose Tolerance and Plasma Lipid Levels in Older Men and Women

Abstract: Eleven healthy men and women (63 ±1 years) participated in a 12-month endurance-training program to determine the effects of low-intensity and high-intensity training on glucose tolerance and plasma lipids in older persons Plasma glucose, insulin, and C-peptide concentrations were measured for three hours after ingestion of 100 g of glucose and the total areas under the respective curves were calculated Total plasma lipids and lipoprotein concentrations were determined during fasting Maximal oxygen uptake increased 12% during six months of low-intensity training; a further 18% increase occurred during an additional six months of high-intensity training Glucose tolerance, which was normal initially, was not significantly changed after training However, the total area for insulin was 8% lower after low-intensity training, and 23% lower after high-intensity training, compared with before training C-peptide concentrations were similarly reduced Plasma lipid and lipoprotein concentrations were unchanged after low-intensity training, but high-intensity training resulted in an increase in high-density lipoprotein cholesterol and a reduction in triglycerides These results demonstrate that older persons respond to prolonged, high-intensity endurance training with an increase in sensitivity to insulin and a favorable alteration in their plasma lipoprotein-lipid profile (JAMA1984;252:645-649)