Showing papers in "JAMA Internal Medicine in 1979"

Some health benefits of physical activity. The Framingham Study.

Abstract: Examination of activity in the Framingham cohort reveals that this is a sedentary population. Overall mortality and mortality due to cardiovascular and ischemic heart disease were inversely related to the level of physical activity for men. The effect of being sedentary on mortality is rather modest compared to the effects of other risk factors but, in mortality due to ischemic heart disease, it persists when these factors are taken into account. For women, the effect is negligible. In strokes, occlusive peripheral arterial disease, and cardiac failure, an inverse relationship is noted, but does not reach statistical significance. There is a statistically significant association with incidence of ischemic heart disease and with incidence of all forms of cardiovascular disease when they are taken together. Little correlation was noted between physical activity level (at the generally low level found) and the level of major risk factors. (Arch Intern Med139:857-861, 1979)

Sampling variability on percutaneous liver biopsy.

Abstract: Sampling variability of liver biopsy was determined in three consecutive biopsy specimens obtained from each of 118 patients immediately prior to autopsy. No sampling variability was found for fatty liver, alcoholic hepatitis, nonspecific hepatitis, fulminant hepatitis, leukemic infiltrate, and venous congestion. Cirrhosis was diagnosed in 80% of cases at the first biopsy but in all cases after three biopsies. Chronic aggressive and chronic persistent hepatitis were diagnosed correctly in two of three cases each at the first biopsy, and in all cases after three biopsies. Metastatic carcinoma was detected in 46% of cases at the first biopsy and in 69% after three biopsies. Granulomas were missed once on the first biopsy, but found on a subsequent biopsy. The amounts of fat and fibrosis in the biopsy specimens often were not representative of the amounts present at autopsy. (Arch Intern Med139:667-669, 1979)

Drug Dependence, A Possible New Risk Factor for Tuberculosis Disease

Abstract: A study was performed to assess the risk of drug-dependent persons for developing tuberculosis. Tuberculosis prevalence was 3,740/100,000 drug-dependent inpatients compared with 584/100,000 non-drug-dependent discharges. In another program, prevalence was 3,750/100,000; in the New York Methadone Program, prevalence was 2,652/100,000 patients in Harlem and 1,372/100,000 city-wide. The city-wide prevalence rate in the entire population was 86.7/100,000 in 1971 and 64.7/100,000 in 1973. Similar elevations in incidence also were found in drug-dependent vs non-drug-dependent populations. Our data show that disease rate is elevated in drug-dependent populations, suggesting that drug dependency reflects a high-risk situation for tuberculous infected individuals developing tuberculosis disease. We suggest that infected drug-dependent persons (tuberculin positive) be considered for preventive therapy with isoniazid, which can be piggybacked onto a drug treatment program. ( Arch Intern Med 139:337-339, 1979)

Detection and treatment of occupational lead nephropathy

Abstract: Reduced glomerular filtration rates (GFR less than 90 ml/min/1.73 sq m) were found in 21 of 57 lead workers in whom excessive body lead burdens had been shown by the urinary excretion of more than 1,000 microgram of lead per day during an edetate disodium calcium lead-mobilization test. In 12 patients, renal biopsies confirmed the diagnosis of occupational lead nephropathy and further excluded other possible causes of kidney disease. Glomerular and tubular immunoglobulin deposition in seven of eight biopsy specimens examined by immunofluorescent microscopy raises the possibility that an autoimmune response may contribute to the interstitial nephritis of occupational lead nephropathy. The GFR increased 20% or more in four of eight patients treated with 1 g of edetate disodium calcium three times weekly for from six to 50 months, further confirming the diagnosis of lead nephropathy and indicating a favorable response to prolonged chelation therapy.

The Effect of Infusion of Mannitol-Sodium Bicarbonate on the Clinical Course of Myoglobinuria

Abstract: Twenty patients who had evidence of myoglobinuria were treated with intravenous infusions of mannitol and sodium bicarbonate. Nine patients (group 1) responded with higher urine output, and continued infusion improved renal function; none required dialysis and all survived. Eleven patients (group 2) did not respond to the infusion, and required an average of 5.3 (range, 0 to 11) dialyses; one patient died. There was no significant difference in initial BUN level, creatinine level, BUN/ creatinine ratio, or fractional sodium excretion level between the two groups. However, group 2 patients had a significantly higher creatine phosphokinase (CPK) level, serum phosphate level, and hematocrit reading initially than did group 1, indicative of more severe muscle injury and hemoconcentration. These results demonstrate that some patients with myoglobinuria will respond to infusion of mannitol and sodium bicarbonate. This treatment may be effective in altering the clinical course of myoglobinuric acute renal failure. ( Arch Intern Med 139:801-805, 1979)

"Acute chest syndrome" in adults with sickle cell anemia. Microbiology, treatment, and prevention.

Abstract: Fifty-two episodes of fever, chest pain, increased leukocytosis, and pulmonary infiltrate ("acute chest syndrome") were studied in 28 adults with sickle cell anemia. Possible bacterial pathogens were identified in sputum cultures from less than half of the episodes; no pneumococci were found, and Staphylococcus aureus was the only bacterium associated with a longer illness than that seen when only normal flora were recovered. Much disease diagnosed as "pneumonia" in adults with sickle cell anemia is probably pulmonary infarction. Many of these patients will recover with no more than modest supportive care; if antibiotics are used they should be directed against S aureus (and possibly Hemophilus species). Pneumococcal polysaccharide vaccine has great potential for preventing life-threatening infection in children with sickle cell anemia, but may not change the incidence or severity of the acute chest syndrome in adults. ( Arch Intern Med 139:67-69, 1979)

Incidence and Outcome of the Respiratory Distress Syndrome in Gram-Negative Sepsis

Abstract: Twenty cases of the adult respiratory distress syndrome (ARDS) in 86 cases of Gram-negative bacteremia were identified. Features of Gram-negative bacteremia associated with the development of ARDS included a history of cardiac disease, hypotension, and thrombocytopenia. The mortality of patients with and without ARDS was 90% and 55%, respectively. The association of hypotension and thrombocytopenia with the subsequent development of ARDS suggests the possible role of endotoxin-induced coagulopathy in this complication. (Arch Intern Med139:867-869, 1979)

Serum Electrolyte and Acid Base Composition: The Influence of Graded Degrees of Chronic Renal Failure

Abstract: Data from 41 ambulatory patients with graded degrees of uncomplicated, chronic renal failure were used to define the quantitative relationship between serum acid-base and electrolyte composition and the serum creatinine level. Even in patients with only moderate renal insufficiency, serum total carbon dioxide (tCO 2 ) content was reduced significantly. This early fall in tCO 2 was offset by an increase in serum chloride (Cl-), serum undetermined anion concentration (A-) remaining normal. In patients with more severe degrees of renal insufficiency, further decrements in tCO 2 occurred that were proportional to the increment in serum creatinine. These latter decrements in tCO 2 were associated with equivalent increments in A-, serum Cl-- remaining unchanged at the elevated level observed during moderate renal insufficiency. Confidence limits of 95% for tCO 2 and A were calculated from the data. ( Arch Intern Med 139:1099-1102, 1979)

In search of the gold standard for compliance measurement.

Abstract: With the help of strong societal pressures, we are learning to acknowledge several nontraditional factors in medicine. We must now consider relative costs, absolute effectiveness, and "informed" patient-consumers. These new concerns form part of a larger trend to translate more directly the dramatic scientific advances of recent years into the practical arena. Amid cries for parsimonious medicine and maximized benefit, compliance has emerged as a major issue. The problem of noncompliance is hardly new. But its recognition and acknowledgment have come haltingly, apparently since few health professionals considered it worthy of attention and, probably more importantly, because few of them believed in their responsibility. The concept of noncompliance as reflecting simple patient inadequacy or even depravity continues to prevail. Only in recent years have we learned enough about the phenomenon to define partially its sheer complexity, 1 innumerable determinants, 2 difficult predictability, 3-4 and public policy implications. 5 Most of

Use of Quantitative Bacteriologic Techniques to Diagnose Catheter-Related Sepsis

Abstract: A case of polymicrobial sepsis occurred in a patient who had a permanent indwelling hyperalimentation catheter. Because it was undesirable to remove the catheter, quantitative bacteriologic techniques were used to determine whether the catheter was the source of sepsis. Blood drawn from a peripheral vein had 25 colonies per milliliter whereas blood drawn through the catheter had more than 10,000 colonies per milliliter. On the basis of these results, the catheter was removed. The catheter tip was found to be infected with the same organisms that were present in the blood. Quantitative bacteriologic techniques may prove useful in diagnosing catheter-related sepsis when it is undesirable to remove the catheter. ( Arch Intern Med 139:482-483, 1979)

Acute Leukemia and Immunosuppressive Drug Use A Review of Patients Undergoing Immunosuppressive Therapy for Non-neoplastic Diseases

Abstract: We have reviewed 61 reported cases of acute leukemia developing in patients who had previously received immunosuppressive agents for non-neoplastic disorders. In three patients the diagnosis of acute leukemia was made less than six months after the first exposure to immunosuppressive drugs and was, therefore, considered coincidental. Among the remaining 58 patients, most diagnoses were of myeloblastic or myelomonocytic leukemia. The underlying diagnoses in most of the 58 patients were rheumatoid arthritis or renal disease or renal transplant. Thirty patients had received alkylating agents exclusively, 10 had received antimetabolites only, while the remaining 18 patients had received multiple therapeutic modalities including antimetabolites, alkylating agents, and/or radiation. Most patients had also received large amounts of corticosteroids. Although we do not have the overall denominator of population at risk, the relatively high proportion of patients who had received alkylating agents before developing acute leukemia does suggest a causal relationship, and one might, therefore, hesitate before using such drugs in non-life-threatening diseases. (Arch Intern Med139:461-466, 1979)

Immune-complex deposition in the eye in systemic lupus erythematosus.

Abstract: A patient with systemic lupus erythematosus (SLE) and lupus retinopathy showed resolution of subretinal edema documented with fluorescein angiography. Subsequently at autopsy, immunofluorescence studies disclosed ocular deposition of immunoglobulins in the vascular layer of choroid capillaries and basement membranes of ciliary processes and bulbar conjunctivas. To our knowledge, these findings represent the first reported documentation of probable immune-complex ocular vasculitis in lupus retinopathy using immunofluorescent techniques, and they support the hypothesis that lupus retinopathy is caused by immune complex deposition as are other manifestations of SLE. ( Arch Intern Med 139:1312-1313, 1979)

Progesterone therapy in obese patients with sleep apnea.

Abstract: Seven morbidly obese patients with sleep-related upper airway obstruction (UAO) were studied before and during progesterone treatment. All subjects had severe daytime somnolence, and five of the seven had congestive heart failure. All subjects were studied for one or two consecutive baseline nights in the sleep laboratory. Six of the seven subjects showed a mean of greater than 100 UAOs. Patients were treated for two to four weeks with medroxyprogesterone acetate, 20 mg three times daily. At the end of the treatment period, the sleep studies were repeated. There was no significant difference in the incidence, mean duration, or rate per minute of apneic episodes occurring before and with progesterone treatment. Severe hypoxemia during sleep persisted with treatment, as did the occurrence of cardiac arrhythmias. There was a significant improvement in the waking Pao 2 with progesterone treatment. ( Arch Intern Med 139:109-111, 1979)

Measurement of medication compliance in a clinical setting. Comparison of three methods in patients prescribed digoxin

Abstract: Medication compliance is an important medical process, and useful methods are needed to measure compliance in clinical practice. Interview, pill count, and serum digoxin concentration (SDC) were compared in 173 patients prescribed digoxin to determine (1) feasibility, ease, timeliness; (2) reasons for noncompliance; and (3) validity of interview and pill count compared with SDC. All patients were interviewed; among 33 (19%) not taking their medication correctly, nine (5%) did not know how. Pill counts were possible for 68 patients (39%). One patient had a correct pill count. Steady-state SDCs were obtained for 143 patients (83%), but were not available during patients' visits. The SDCs for 25 patients were less than 0.50 ng/mL. Interviews correlated with SDCs, pill counts did not. Pill counts and SDCs required telephoning patients before appointments. In clinical practice, interview may be the most useful methof of measuring medication compliance.

The beneficial effects of verapamil in chronic atrial fibrillation.

Abstract: Digitalis preparations frequently fail to control heart rate in many patients who have chronic atrial fibrillation, particularly during physical exertion. The effects of orally administered verapamil, 160 to 240 mg/day, on the heart rate at rest and during mild exercise were studied in 23 digitalized patients with chronic atrial fibrillation of various causes. Verapamil substantially reduced the excessive heart rate response to exercise in well-digitalized patients who had chronic atrial fibrillation. ( Arch Intern Med 139:747-749, 1979)

Bacteremic Infection in Hemodialysis

Abstract: This is a retrospective study of 133 episodes of bacteremic infection in 112 hemodialysis patients. The frequency of bacteremic infection was 9.5% in patients with chronic renal failure and 10.9% in patients with acute renal failure. In patients with acute renal failure, pneumonia and intra-abdominal abscess were the most frequent sources of septicemia. Sepsis was usually due to Gram-negative organisms and mortality was high. In patients with chronic renal failure, infection of the shunt or fistula was the most common cause, was frequently due to Staphylococcus organism, and had a more favorable survival rate. Gram-negative septicemia from a nonaccess source in patients with chronic renal failure was associated with a higher mortality. Bacterial endocarditis and septic pulmonary emboli occurred in 3.6% of septic episodes and 0.35% of patients at risk and had very low mortality. A low threshold for obtaining blood cultures and early antibiotic treatment are believed to be important in the treatment of bacteremic infections in patients undergoing long-term hemodialysis. ( Arch Intern Med 139:1255-1258, 1979)

Serious staphylococcal infections with strains tolerant to bactericidal antibiotics.

Abstract: The clinical response in 20 cases of serious staphylococcal infection was compared with the in vitro resistance or "tolerance" of the infectingStaphylococcusto killing by antibiotics used in treatment. Cases were divided into two groups: (1) patients who initially received nonbactericidal antibiotics (ten cases), and (2) patients who initially received bactericidal antibiotics with or without nonbactericidal antibiotics. Mortality due to uncontrolled staphylococcal infection was 40% (4/10) in group 1 as compared with no mortality (0/10) in group 2. The duration of positive cultures after start of therapy in group 1 (mean, 6.1 days) was significantly longer than that in group 2 (mean, 1.3 days). The duration of fever after start of therapy in group 1 was not significantly different when compared with group 2. (Arch Intern Med139:1026-1031, 1979)

Effect of Parathyroidectomy on Anemia in Chronic Renal Failure

Abstract: Fourteen patients with chronic renal failure underwent parathyroidectomy. Postoperatively, seven patients exhibited a rise in hematocrit reading, but seven others did not. Responders had more severe bone disease and lower initial hematocrit values than did nonresponders. Marrow fibrosis was slightly more prominent in responders. Current concepts of marrow erythropoietic inhibition in renal failure suggest a toxic serum factor as the cause. This report fails to support parathyroid hormone as the toxic agent directly responsible for marrow inh bition. Rather, parathyroid hormone may contribute to anemia in renal failure by causing marrow fibrosis, a process sometimes reversible by successful therapy of hyperparathyroidism. (Arch Intern Med139:889-891, 1979)

Vascular disease in diabetes: pathophysiological mechanisms and therapy.

Abstract: Vascular disease is the major cause of morbidity and mortality in diabetes mellitus. Data from the recent comprehensive report from the National Commission on Diabetes suggested that diabetics are two times more prone to heart attacks, five times more prone to gangrene, 17 times more prone to kidney failure, and 25 times more prone to blindness than nondiabetics.1These sobering statistics reflect the ravages of accelerated atherosclerosis plus a relatively specific form of microvascular disease in multiple organ systems in the diabetic. Recent progress has been made in the understanding of the mechanisms involved both in large-vessel disease (macrovascular disease) and small-vessel disease (microvascular disease) in patients with diabetes mellitus. With an increased understanding of the mechanisms involved, intelligent decisions about therapy may be more easily made. We briefly review the current thoughts about the pathophysiologic features of diabetic vascular disease and make therapeutic recommendations based on these observations.

Intravenous Antibiotic Therapy at Home

Abstract: Many patients who are hospitalized for intensive intravenous (IV) antibiotic therapy of serious infections are not disabled. Following a short period of treatment in the hospital and after their medical problem has stabilized, these patients can safely receive IV antibiotics at home. Patients who had osteomyelitis or infective endocarditis were selected for this study. Utilizing an IV nurse team, patients were instructed in the administration of the antibiotic. They returned to the hospital every 48 hours to have their IV catheter changed and to receive a new supply of antibiotic. There was a substantial monetary saving with each treatment course (at least $1,600 per patient), and, in addition, the patients were much more comfortable at home and some returned to work or to school. ( Arch Intern Med 139:413-415, 1979)

Arrhythmogenic Effects of Orally Administered Bronchodilators

Abstract: The respiratory and circulatory effects of orally administered ephedrine sulfate, 25 mg, aminophylline, 400 mg, terbutaline sulfate, 5 mg, and placebo were evaluated in 20 patients with ventricular arrhythmia by a double-blind crossover method. The bronchodilator effect of terbutaline was similar to that of aminophylline over four hours but superior to ephedrine at the fourth hour. Both terbutaline and ephedrine exhibited chronotropic effects, with the effect of terbutaline greater than that of ephedrine at the fourth hour. The effect of aminophylline on heart rate did not differ from placebo. Only terbutaline was associated with an increase in ventricular ectopic beats. Ventricular tachycardia occurred in three patients treated with terbutaline and in one patient with ephedrine. There were no significant changes in blood pressure. Orally administered terbutaline should not be regarded as safer than orally administered ephedrine or aminophylline in patients with arrhythmias. (Arch Intern Med139:434-437, 1979)

Comparison of nonseptic and septic bursitis. Further observations on the treatment of septic bursitis.

Abstract: Of 30 cases of olecranon and prepatellar bursitis, ten were septic Fever, tenderness, peribursal cellulitis, and skin involvement over the bursa were more common in the septic cases A high leukocyte count, low bursal-to-serum glucose ratio, and positive Gram-stained smear of the bursal fluid distinguished septic from nonseptic bursitis Rheumatoid arthritis and gout may be accompanied by nonseptic bursitis Septic bursitis may be associated with a sympathetic sterile effusion in a neighboring joint or adjacent fascial space The duration of antibiotic treatment necessary to sterilize bursal fluid was proportional to the length of time infection had been present A prospective antibiotic program disclosed an average of 12 days for successful therapy A bactericidal agent against penicillin-resistant Staphylococcus aureus is the drug of choice ( Arch Intern Med 139:1269-1273, 1979)

Clinical Ethics and Clinical Medicine

Abstract: Tn this issue of theArchives, a new editorial department is introduced It will appear occasionally and will present the views of practicing physicians on a broad range of clinical problems that force them to confront directly moral and ethical questions arising in their routine practice The articles will be written by clinicians, and will be directed toward an audience of practicing physicians This new section will be called CLINICAL ETHICS, reflecting the fact that, in the practice of medicine, clinical and ethical issues are deeply interdependent THE RISE OF BIOMEDICAL ETHICS Clinical ethics, which focuses on issues that confront the physician in his daily interactions with patients, is to be contrasted with biomedical ethics (BME), which is greatly concerned with public policy issues In the past 15 years, there has been a remarkable rise of interest in BME; it has captured the fancy of the public The media have

Serum thyroid hormone levels in patients with liver disease.

Abstract: Levels of serum triiodothyronine (T 3 ), reverse triiodothyronine (rT 3 ), and thyroxine (T 4 ) were determined in 29 patients with alcoholic cirrhosis, seven patients with acute hepatitis, and 14 control patients hospitalized for chronic disease. Serum T 3 levels were decreased significantly and serum rT 3 levels increased significantly in the patients with alcoholic cirrhosis. Serum T 3 and T 4 levels were lower and rT 3 levels higher in the cirrhotic patients who died within three months of the study compared with those who survived. A combination of prothrombin time, aminopyrine breath test results, and rT 3 and T 3 determinations gave significant predictive information about survival in patients with cirrhosis. The data suggest that assay of serum thyroid hormone levels together with prothrombin time and the aminopyrine breath test may be helpful in assessing the course and prognosis of patients with liver disease. ( Arch Intern Med 139:1117-1120, 1979)

Enhanced cardiac effect of digoxin during quinidine treatment.

Abstract: Quinidine causes an increase in the serum digoxin concentration. Three patients were studied to determine if the increase in serum concentration is paralleled by an increase in the cardiac effect of digoxin. Each patient's clinical condition and serum digoxin concentration were stable when quinidine administration was begun. In all three patients, serum digoxin concentrations increased significantly after beginning quinidine, and decreased when quinidine was discontinued. While taking quinidine, all three patients had ECG findings that suggested enhanced digitalis effect and one patient had clinical evidence of an increased hemodynamic effect. These effects paralleled the increases in serum digoxin concentration. Our findings suggest that the increase in serum digoxin concentration, which occurs after beginning quinidine, is associated with an increase in the effect of digoxin on the heart. ( Arch Intern Med 139:519-521, 1979)

Thyroid axis in patients with Cushing's syndrome.

Abstract: Thyroid hormone values and serum thyrotropin (thyroidstimulating hormone [TSH]) responses to the intravenous administration of 400 μg of protirelin were determined in ten patients with Cushing's syndrome and in ten matched normal subjects. In patients with Cushing's syndrome, the serum thyroxine (T 4 ) level was mildly depressed and free T 3 level was normal. The mean ( ± SD) concentrations of serum triiodothyronine (T 3 ) and free T 3 were both reduced in patients compared with normal subjects ( P P 3 and free T 3 levels are due to a glucocorticoid suppressive effect on the peripheral conversion of T 3 to T 3 . The protirelin test is of limited value in assessing the thyroid status because the response of TSH is frequently blunted or absent due to glucocorticoid excess. ( Arch Intern Med 139:767-772, 1979)

Control of refractory cardiac arrhythmias with amiodarone.

Abstract: Amiodarone hydrochloride was used to treat 19 patients with symptomatic arrhythmias refractory to quinidine sulfate, procainamide hydrochloride, disopyramide phosphate, antazoline hydrochloride, lidocaine hydrochloride, bretylium tosylate, propranolol hydrochloride, phenytoin sodium, and practolol acetanilide given to the limit of tolerance. In 17 patients, attacks were completely controlled. Arrhythmias treated successfully included recurrent supraventricular tachycardias, recurrent supraventricular tachycardias with Wolff-Parkinson-White syndrome, and refractory ventricular arrhythmias including recurrent ventricular tachycardia and ventricular fibrillation complicating acute coronary heart disease. Control was confirmed by continuous ECG monitoring both in the hospital and when ambulatory and was maintained for up to four years. Attacks of supraventricular tachycardia were reduced from 7.9/mo to one attack every 53.5 months on amiodarone. Hospital admissions for arrhythmias were reduced from 34 the year before treatment to none the year after. Therefore, amiodarone is an excellent drug for control of many refractory arrhythmias, but two patients with recurrent atrial fibrillation were refractory to this treatment. ( Arch Intern Med 139:425-428, 1979)

Bone Marrow Necrosis and Degeneration

Abstract: Bone marrow necrosis, regarded as a rare finding in specimens from living patients, has been associated with a poor prognosis in patients with serious hematologic diseases and metastatic carcinoma. Two patients with extensive idiopathic bone marrow necrosis and a relatively benign course of illness were found. Therefore, we examined 500 consecutive bone marrow biopsy specimens that were obtained in a university hospital complex. Review of this material showed evidence of necrosis and degenerative changes of variable severity in one third of the biopsy specimens. It was found with approximately the same incidence in patients who underwent bone marrow biopsy for either neoplastic or nonneoplastic disorders; an increased prevalence was not observed in the group of patients who had received chemotherapy. Based on these observations, we believe necrosis and degeneration of the bone marrow is a commonplace finding that is frequently overlooked in a wide variety of acute and chronic disorders, and that requires further investigation to determine its clinical importance. ( Arch Intern Med 139:905-911, 1979)

Retinal Arteriolar Changes as an Indicator of Coronary Artery Disease

Abstract: Funduscopic examination was performed in 70 nondiabetic, nonhypertensive patients without valvular heart disease undergoing coronary angiography for evaluation of chest pain syndromes to determine if retinal arteriolar changes could reliably predict presence of coronary artery disease. Retinal arteriolar changes were graded with respect to light reflex, vessel caliber, arteriovenous crossing defects, and vessel tortuosity without knowledge of angiographic findings. Each coronary vessel was graded with respect to its most occlusive lesion by angiography; coronary index was derived for each patient without knowledge of eye findings. Abnormal light reflex changes were the most sensitive indicators of presence and extent of coronary artery disease. Abnormal vessel tortuosity and decreased caliber were less sensitive but more specific; their presence also suggested more extensive coronary lesions. Thus, funduscopic examination demonstrating specific retinal arteriolar lesions may indicate presence of coronary artery disease and may correlate with extent of lesions in selected patients. (Arch Intern Med139:1139-1141, 1979)

Upper Airway Obstruction as a Complication of Oral Anticoagulation Therapy: Report of Three Cases

Abstract: While taking orally administered anticoagulants, three patients had hemorrhages into their retropharyngeal and submandibular spaces, suffering eventual acute airway obstruction. One of the patients died. Despite the life-threatening nature of this complication of anticoagulant therapy, the diagnosis was obscure and initially veiled in complaints of sore throat or hoarseness, suggesting infection. Thorough investigation of such complaints is necessary in patients receiving anticoagulation therapy. If a hematoma is discovered, the patient should be admitted to the hospital for close observation and prompt reversal of anticoagulation with plasma. Intubation or tracheostomy also may be required. ( Arch Intern Med 139:1151-1153, 1979)