Showing papers in "JAMA Internal Medicine in 1988"

Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults

Abstract: • This report of an expert panel of the National Cholesterol Education Program provides new guidelines for the treatment of high blood cholesterol in adults 20 years of age and over. Total cholesterol levels are classified as follows: ( Arch Intern Med 1988;148:36-69)

The 1988 Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure

Abstract: • The National High Blood Pressure Education Program has released three Joint National Committee reports and a task force report on the detection, evaluation, and treatment of high blood pressure. Like its predecessors, the 1988 Joint National Committee report was developed using the consensus process; it is based on the latest scientific research and reflects the state of the art regarding hypertension management. This report updates findings of previous reports in several respects: it broadens the step-care approach to provide more flexibility for clinicians; encourages greater patient involvement in the treatment program; emphasizes a consideration of the quality of life in the management of patients; and addresses the cost of care. It also provides more emphasis on control of other risk factors for cardiovascular disease; includes a discussion of the new cholesterol guidelines; recommends a reduction in alcohol consumption; and discusses the use of calcium and fish oil supplementation. This document expands earlier reports on special populations, including blacks and other racial and ethnic minority groups, young and elderly patients, pregnant patients, surgical candidates, and hypertensive patients with cerebrovascular disease, coronary artery disease, left ventricular hypertrophy, congestive heart failure, peripheral vascular disease, renal disease, chronic obstructive pulmonary disease or bronchial asthma, gout, diabetes mellitus, and hyperlipidemia. The report also updates previous drug tables to include new drugs, revised recommended doses of some drugs, and drug interactions. Consideration of step-down therapy after blood pressure has been controlled is suggested. This report is intended as a guide for practicing physicians and other health professionals in their care of hypertensive patients and as a reference for those participating in the many community high blood pressure control programs throughout the country. (Arch Intern Med1988;148:1023-1038)

Hospital-Acquired Candidemia: The Attributable Mortality and Excess Length of Stay

Abstract: • Between 1977 and 1984, estimates of hospital-acquired bloodstream infections caused byCandidaspecies increased in the United States from 0.5 to 1.5 per 10000 admissions (National Nosocomial Infection Study data). We examined crude and attributable mortality rates and excess length of stay in 88 closely matched pairs of cases and controls with illnesses occurring between July 1983 and December 1986. The crude mortality rates for cases and controls were 57% and 19%, respectively; thus the attributable mortality rate was 38% with a 95% confidence interval of 26% to 49%. The risk ratio was 2.94 with a 95% confidence interval of 1.95 to 4.43. The median length of stay was 48 days for all cases and 40 days for all controls. An analysis of the length of stay for the 34 matched pairs that survived showed a median of 70 days for cases and 40 days for controls.Candidabloodstream infections represented 10% of all nosocomial bloodstream infections in the period studied at our University Hospital; they are associated with a significant medical and economic burden well above that expected of the underlying diseases alone. (Arch Intern Med1988;148:2642-2645)

Precipitating factors leading to decompensation of heart failure. Traits among urban blacks.

Abstract: • Potential precipitating factors that led to cardiac decompensation and subsequent hospital admission for heart failure were examined in 101 patients in a large public hospital serving a predominantly working-class minority population. Ninety-seven percent of patients were black; their age was 59± 14 years (mean ±SD); on average, they were hospitalized three times in the preceding year for problems related to their heart failure. Potential precipitating factors for decompensated heart failure were identified in 93% of patients. Lack of adherence to the prescribed medical regimen was the most commonly identified causative factor and was noted in 64% of the cases; noncompliance with diet amounted to 22%, with drugs to 6%, and with the combination of drugs and diet to 37%. Other factors also related to hospitalization were cardiac arrhythmias (29%), emotional/environmental issues (26%), inadequately conceived drug therapy (17%), pulmonary infections (12%), and thyrotoxicosis (1%). Thus, the key preventive measure necessary in at least two thirds of patients centered around better adherence to drug and/or diet regimen, highlighting the precept that better patient education is mandatory if we are to minimize the number of hospital admissions for decompensated heart failure. (Arch Intern Med1988;148:2013-2016)

Factors Predictive of Acute Renal Failure in Rhabdomyolysis

Abstract: • In a historical cohort study, acute renal failure developed in 165% of 157 patients with rhabdomyolysis over a two-year study period Underlying clinical, laboratory, and causative factors associated with the development of acute renal failure were examined Factors predictive of renal failure in this setting, determined by multiple logistic regression analysis, included the degree of serum creatine kinase, serum potassium, and serum phosphorus level elevation; the degree of depression of serum albumin level; and the presence of dehydration at presentation or sepsis as the underlying cause The predictive model that was developed correctly classified 93% of subjects and was statistically validated (Arch Intern Med1988;148:1553-1557)

The Medical Course of Cancer Patients With Fever and Neutropenia Clinical Identification of a Low-Risk Subgroup at Presentation

Abstract: • To determine whether cancer patients with fever and neutropenia differ in their medical stability, 261 medical records of 184 cancer patients who were hospitalized with fever and neutropenia and treated with conventional antibiotic therapy were studied to determine whether their presenting clinical characteristics influenced the likelihood of subsequent clinical events thought to require urgent medical attention. Overall, serious medical complications, including those without an obvious relationship to infection, occurred in 56 patient courses (21%). We distinguished three clinically determined subgroups of our study population at significantly higher risk than the remaining patient group, which seemed to be at low risk. Major complications occurred in 34 (34%) of 101 inpatients, 12 (55%) of 22 outpatients with concurrent comorbidity requiring inpatient care, and eight (31%) of 26 outpatients without concurrent comorbidity requiring inpatient care but with uncontrolled cancer. However, the remaining patients, who presented as outpatients without significant comorbidity or uncontrolled cancer, had major complications in only 2% of 112 hospitalizations. These results suggest that it may be possible to assess the medical stability of patients with fever and neutropenia based on presenting clinical features. If confirmed prospectively, these results may enable clinicians to identify groups of medically stable patients for whom conventional supportive care, including appropriately administered antibiotics, may be given safely under medical supervision of less intensity or of shorter duration than conventional treatment in the acute-care hospital setting. (Arch Intern Med1988;148:2561-2568)

Nosocomial infection and fatality in medical and surgical intensive care unit patients.

Abstract: • We prospectively studied 526 patients admitted to the medical intensive care unit (MICU) and 799 patients admitted to the surgical intensive care unit (SICU) at a municipal hospital over a 20-month period. Rates of nosocomial infection were higher in the SICU patients (31% vs 24%). The SICU patients had more urinary tract infections, bacteremias, and wound infections, and the MICU patients were older, had higher acute physiology scores on admission and were more often admitted with shock or coma. The SICU patients were more likely to have received prior antibiotic therapy and had significantly higher numbers of endotracheal tubes, arterial lines, central venous lines, and indwelling bladder catheters. Of the 23 variables univariately associated with nosocomial infection, only five remained significant after entry into stepwise regression models. The MICU patients had a higher fatality rate in the MICU than did the SICU patients (18% vs 10%), but the relative risk of a death following nosocomial infection was 3.5 for both groups. Thirty variables were significantly associated with hospital fatality; nine remained significant after analysis by stepwise logistic regression. (Arch intern Med1988;148:1161-1168)

Clinical symptoms and length of survival in patients with terminal cancer.

Abstract: Planning terminal care for patients with malignant neoplasms is difficult, in part, because accurate measures of prognosis have not been defined. Using data from the National Hospice Study, we examined the correlation of 14 easily assessable clinical symptoms with survival in patients with terminal cancer. Performance status was the most important clinical factor in estimating survival time, but five other symptoms had independent predictive value as well (shortness of breath, problems eating or anorexia, trouble swallowing, dry mouth, and weight loss). We generated four parametric accelerated time survival models to estimate survival in patients with combinations of these symptoms and validated the log-normal model on the entire data set. This model was unaffected by patient age, sex, primary tumor type, or site. Our findings illustrate the value of biologically "soft" clinical data in predicting survival in patients with terminal cancer. The prevalence of similar symptoms among patients with cancer of various primary and metastatic sites also supports the concept of a common final clinical pathway in patients with advanced malignant neoplasms.

Calf Deep Venous Thrombosis: A Wolf in Sheep's Clothing?

Abstract: • To determine the natural history of calf deep venous thrombosis (C-DVT), an analytic review of the 20 relevant English-language papers published since 1942 was performed. Remarkably little methodologically sound research on this subject was found. However, available evidence suggests that C-DVT propagates to the thigh in up to 20% of cases and that propagation invariably occurs before embolization. No fatal emboli were reported in patients presenting with isolated C-DVT. Traditional anticoagulation treatment with heparin sodium and warfarin sodium of symptomatic patients with C-DVT appears to prevent extension, embolization, and early recurrence. There is no convincing evidence that C-DVT leads to chronic venous insufficiency or whether the risks of anticoagulation exceed the risks of no treatment. As an option to anticoagulation, physicians may choose to follow patients with C-DVT with serial impedance plethysmography, treating only if there is evidence of proximal extension. (Arch Intern Med1988;148:2131-2138)

Magnesium Metabolism: A Review With Special Reference to the Relationship Between Intracellular Content and Serum Levels

Abstract: † Magnesium (Mg++) is a ubiquitous element in nature, playing a role in photosynthesis and many metabolic functions in humans. All enzymatic reactions that involve adenosine triphosphate have an absolute requirement for Mg++. Levels of Mg++ are controlled by the kidneys and gastrointestinal tract and appear closely linked to calcium, potassium, and sodium metabolism. The clinical manifestations and causes of abnormal Mg++ status are protean. Testing for altered Mg++ homeostasis is problematic. Serum levels, which are those generally measured, reflect only a small part of the total body content of Mg++. The intracellular content can be low, despite normal serum levels in a person with clinical Mg++ deficiency. Future directions in research related to intracellular content of Mg++ are discussed. Treatment of altered Mg++ status depends on the clinical setting and may include the addition of a potassium/Mg++ —sparing drug to an existing diuretic regimen. Guidelines for therapy are given. (Arch Intern Med1988;148:2415-2420)

Tube Feedings in Elderly Patients: Indications, Benefits, and Complications

Abstract: • During an 11-month period, 70 tube-fed patients aged 65 to 95 years were studied prospectively to determine the indications, benefits, and complications of enteral alimentation. Indications for alimentation were refusal to swallow (35 patients [50%]), dysphagia without obstruction (33 [47%]), and esophageal obstruction (two [3%]). Nasogastric tubes (NGTs) were used initially in 69 patients; 15 of these subsequently required a gastrostomy tube (GT). One patient was treated initially with a gastrostomy. Indicators of nutritional status included weight, hemoglobin level, hematocrit, and serum albumin level. During the first two weeks the most common problems in the NGT group were agitation and self-extubation (36 patients [67%]) and aspiration pneumonia (23 [43%]). In GT patients the most common early problems were aspiration pneumonia (nine patients [56%]), tube dysfunction (eight [50%]), and agitation and extubation (seven [44%]). The common late problems were aspiration pneumonia (24 patients [44%] in the NGT group and nine [56%] in the GT group), and feeding tube dysfunction in six (38%) of the GT group. Self-extubation as a late problem was limited to the NGT group (21 patients [39%]). Twenty-eight (40%) of the 70 patients died during the study period. (Arch Intern Med1988;148:429-433)

Depression in Elderly Hospitalized Patients With Medical Illness

Abstract: • Depressive symptoms and disorders were identified by structured psychiatric interview in 130 consecutively admitted male inpatients aged 70 years and over. Major depression was found in 11.5% and other depressive syndromes in 23%. While depressive symptoms and syndromes are common among the medically ill, this study demonstrated the need for careful diagnostic assessment of older patients with depressive symptoms before initiating treatment that may itself convey significant risk. Sociodemographic and health characteristics of older men at higher risk for depression were also identified. Patients more likely to be depressed were over age 75 years, had less formal education, experienced cognitive dysfunction, suffered from more severe medical illness (particularly recent myocardial infarction), and had a history of psychiatric illness. Depressive symptoms were also common among patients with renal or neurologic diseases, those having a family history of psychiatric illness, the unmarried, and the more severely disabled. Given the impact of depression on recovery from medical illness, compliance with medical therapy, and costs of extended hospital stays, detection and treatment of this disorder are imperative. (Arch Intern Med1988;148:1929-1936)

Age, sex, and race inequality in renal transplantation.

Abstract: We calculated the chance of receiving a kidney transplant in the United States in 1983, and in the Midwest from 1979 through 1985, considering age, sex, and race. In the United States, 23,026 patients began long-term dialysis and 6112 (27%) received a kidney transplant. Transplant rates were 31% for men and 21% for women. White patients had a 30% rate and nonwhite patients a 20% rate. Patients less than 11 to 35 years old had an 85% rate vs a 3% rate for those older than 56 years. When race, age, and sex were analyzed together, nonwhite patients aged 21 to 45 years had only half the chance of receiving a transplant compared with white patients of the same age and sex. Women aged 46 to 60 years had less than half the chance of receiving a transplant when compared with men of the same age and race. These data show that there are age, sex, and race imbalances in the distribution of renal transplantation. We believe these imbalances only partially have a morally neutral biological, medical, social, and cultural explanation and that there should be a fairer distribution of kidney transplants.

Who gets screened for cervical and breast cancer? Results from a new national survey.

Abstract: • To evaluate the adequacy of cervical and breast cancer screening in the United States, data were analyzed from a 1986 nationwide telephone survey (n=4659) Papanicolaou smears within the recommended three- to five-year interval were reported by 79% of women aged 20 years or older Within the preceding year, 55% of women aged 40 years or older had breast examinations performed by physicians, and 20% of women aged 50 years or older had mammograms Women who were uninsured or lower in socioeconomic status were less likely to have each of these three preventive measures, independent of the age, health status, and frequency of physician visits of the respondent In addition, women aged 50 years or older were less likely to have had Papanicolaou smears (63% vs 89%) and breast examinations (52% vs 68%) than those women aged 20 to 49 years These findings suggest that women who are older, uninsured, or lower in socioeconomic status are at an increased risk for not receiving preventive care, and that screening mammography, although more common than a decade ago, is still markedly underused ( Arch Intern Med 1988;148:1177-1181)

Characterization of the Acute Clinical Illness Associated With Human Immunodeficiency Virus Infection

Abstract: • The clinical and serologic features and immune status of 39 homosexual men who had seroconversion to human immunodeficiency virus positivity were compared with 26 homosexual men who remained seronegative during a six-month period. An acute clinical Illness occurred in 92.3% of seroconverted subjects and 40% of controls. The duration of illness was significantly greater In the seroconverters than the controls (10 + 4.4 days). A general practitioner was consulted by 87.2% of the seroconverters because of the illness, including 12.8% who were admitted to hospital, compared with 20% of controls. The most frequently reported symptoms In the seroconversion group were fever (76.9%); lethargy and malaise (66.7%); anorexia, sore throat, and myalgias (56.4% each); headaches and arthralgias (48.7% each); weight loss (46.2%); swollen glands (43.5%); retro-orbital pain (38.5%); and dehydration and nausea (30.8% each). Lymphadenopathy developed in 75% of seroconverters compared with 4% of controls. Changes in T-cell subsets were not found in controls, but the number of T4 + cells and the T4 + /T8 + ratio decreased significantly in seroconverters. (Arch Intern Med1988;148:945-949)

Two models of implementing informed consent

Abstract: • The doctrine of informed consent has been controversial since its inception. In spite of the professed ideal of improving physician-patient communication, many commentators have argued that it interferes with the relationship. However, the problem may not be the doctrine itself but rather the manner in which it is usually implemented. This article describes two different ways in which informed consent can be implemented. The event model treats informed consent as a procedure to be performed once in each treatment course, which must cover all legal elements at that time. The process model, in contrast, tries to integrate informing the patient into the continuing dialogue between physician and patient that is a routine part of diagnosis and treatment. We suggest that the process model has many benefits. ( Arch Intern Med 1988;148:1385-1389)

The stress of residency. A review of the literature.

Abstract: • A review of empiric studies of the stresses of residency training and descriptions of intervention programs and mental health resource surveys published since 1980 indicated that inadequate sleep and fatigue are major stressors for residents, but they are only part of a more complex situation influenced by time demands, social support, and maturational factors. Other important stressful aspects of training appear to be those that interfere with social support. Increased anger, not depression, is emerging as the predominant mood change during residency, but the effects of any mood change on patient care have not been studied. Despite growing evidence of the need for change in training programs, especially attention to the affiliative needs of residents, few intervention programs have been reported. (Arch Intern Med1988;148:1428-1435)

Management of Cancer During Pregnancy

Abstract: Although cancer during pregnancy is infrequent, its management is difficult for patients, their families, and their physicians. When termination of the pregnancy is unacceptable, decisions regarding the use of irradiation and chemotherapy are complicated by the well-known high risks of abortion and fetal malformation. This risk is concentrated in the first trimester and varies with the choice of chemotherapeutic agents or combinations of agents. There is only minimal evidence of increased risk of malformation or abortion in the second or third trimester. Recent progress in cancer therapy has made cure a reasonable goal, and for some malignant neoplasms, cure is still possible even when initial therapy is modified or delayed. When cure is a reasonable goal, curative therapy should not be compromised by modification or delay. When treatment for cure or significant palliation is not possible, however, the goal should shift to protection of the fetus from damage by the injudicious use of teratogenic cancer therapy. This report will review the available data that may assist in these difficult decisions.

The Mental Health of Patients With a Chief Complaint of Chronic Fatigue: A Prospective Evaluation and Follow-up

Abstract: • To determine the psychiatric morbidity of patients complaining of chronic fatigue, we undertook a prospective evaluation of 100 adults (65 women and 35 men; mean age, 41 years; and mean duration of chronic fatigue, 13 years). The study was conducted in an internal medicine outpatient clinic. In addition to a comprehensive medical evaluation, the patients were administered the 260-item Diagnostic Interview Schedule, a highly structured instrument that enabled the physician-interviewer to make accurate psychiatric diagnoses. A thorough follow-up examination was given an average of 8.4 months later. Sixty-six patients had one or more psychiatric disorders that were considered a major cause of their chronic fatigue (mood disorder, 47 patients; somatization disorder, 15 patients; and anxiety disorder, nine patients). Five patients had medical conditions that were considered a major cause of their fatigue. The complaint of chronic fatigue remained unexplained in 31 patients. In this prospective study, two thirds of cases of chronic fatigue appeared to be caused by psychiatric disorders. A thorough evaluation of the mental health of patients complaining of chronic fatigue could therefore provide pharmacologic and psychotherapeutic approaches and avoid unnecessary and costly medical investigations and therapies. ( Arch Intern Med 1988;148:2213-2217)

Benzodiazepine sedatives and the risk of falling in a community-dwelling elderly cohort.

Abstract: • A prospective study of risk factors for falls in the elderly at home was conducted in a cohort of tenants (N = 169) of six senior-citizen buildings in New Jersey. Within this study, we evaluated whether benzodiazepine sedative use was associated with risk of falling. The mean age (±SD) of the cohort was 79.8 ± 7.3 years, and 80% were women. Monthly telephone interviews yielded a total of 77 falls during an average follow-up time of 5.6 months. Benzodiazepine use at baseline was categorized as either none, as needed, or continuous, eg, nightly use. Continuous use appeared to increase the risk of falling in this cohort (unadjusted relative risk [RR] = 1.53, 95% confidence interval=0.93, 2.52; RR adjusted for age, gender, and follow-up time=1.82, 95% confidence interval=0.92, 3.62). Any use of benzodiazepines was related to multiple falls in persons who fell. The risk of falling from continuous benzodiazepine use may be higher in persons with position-sense loss in the toes (RR=2.00) than in persons without such loss (RR= 1.35). We suggest that periodic review of the need for benzodiazepines in the elderly be made. ( Arch Intern Med 1988;148:2441-2444)

Pernicious anemia. The expected findings of very low serum cobalamin levels, anemia, and macrocytosis are often lacking.

Abstract: • When patients are examined for possible cobalamin deficiency, great stress is often placed on the presence or absence of macrocytosis and anemia and on how low the serum cobalamin level is. The present study, however, shows that only 45 (64%) of 70 consecutively diagnosed patients with pernicious anemia, the most common cause of cobalamin deficiency, had very low cobalamin levels (74 pmol/L [or 100 ng/L]). Anemia was absent in 13 (19%) of the patients, and macrocytosis was absent in 23 (33%) of the patients; such absence was particularly common when cobalamin levels were only slightly or moderately low (74 to 184 pmol/L). Coexisting iron deficiency was responsible for the absence of macrocytosis in nine patients. Of the ten patients with neither anemia nor macrocytosis, neurological disturbance was prominent in six, including four whose only noticeable abnormality was cerebral. These observations indicate that macrocytosis and anemia, two classic features of pernicious anemia, may be overstressed in our diagnostic approach. All subnormal serum cobalamin results are best viewed as pathological until proved otherwise. Emphasis on only very low cobalamin levels risks delaying the diagnosis of pernicious anemia in a substantial proportion of cases, particularly in those without anemia or macrocytosis. (Arch Intern Med1988;148:1712-1714)

Cholesterol-Lowering Effects of Psyllium Hydrophilic Mucilloid for Hypercholesterolemic Men

Abstract: • The effect of psyllium hydrophilic mucilloid on serum cholesterol levels was investigated in 26 men with mild to moderate hypercholesterolemia (range of cholesterol level, 4.86 to 8.12 mmol/L [188 to 314 mg/dL]) in a double-blind, placebo-controlled parallel study. Following a two-week baseline period, subjects were treated for eight weeks with 3.4 g of psyllium or cellulose placebo at mealtimes (three doses per day). All subjects maintained their usual diets, which provided less than 300 mg of cholesterol per day and approximately 20% of energy from protein, 40% from carbohydrate, and 40% from fat. Eight weeks of treatment with psyllium reduced serum total cholesterol levels by 14.8%, low-density lipoprotein (LDL) cholesterol by 20.2%, and the ratio of LDL cholesterol to high-density lipoprotein cholesterol by 14.8% relative to baseline values. The reductions in total cholesterol and LDL cholesterol became progressively larger with time, and this trend appeared to be continuing at the eighth week. Psyllium treatment did not affect body weight, blood pressure, or serum levels of high-density lipoprotein cholesterol, triglycerides, glucose, iron, or zinc. No significant changes in serum lipid levels, body weight, blood pressure, or other serum parameters were observed with placebo treatment. Subject adherence to psyllium treatment was excellent, and no adverse effects were observed. Results of this study show that psyllium is an effective and well-tolerated therapy for mild to moderate hypercholesterolemia. ( Arch Intern Med 1988;148:292-296)

Selective Screening for Abdominal Aortic Aneurysms With Physical Examination and Ultrasound

Abstract: Abdominal aortic aneurysm (AAA) is an important cause of preventable death in older persons. Persistently high rupture mortality rates indicate that these deaths can be prevented only by early detection and treatment of AAA. In an effort to develop an effective and efficient program of AAA detection, we selectively screened a high-risk population. Men aged 60 to 75 years with hypertension and/or coronary artery disease were randomly selected from a general medicine clinic and screened with physical examination and ultrasound. Eighteen previously unsuspected aneurysms, 3.6 to 5.9 cm in size (mean, 4.4 cm), were detected in 201 patients, for a prevalence of 9% (95% confidence interval: 4.7% to 13.3%). The specificity and positive predictive value of ultrasound were each 100%. Abdominal palpation detected only half of these aneurysms, but missed none in patients with an abdominal girth less than 100 cm (n = 6). This degree of sensitivity did not occur with "routine" examinations and requires that the examination be directed specifically toward AAA detection. We conclude that undiagnosed AAAs are common in this large subgroup of the clinic population, that ultrasound is an excellent screening test for AAAs, and that physical examination may be adequate for screening thin patients. We recommend that every two or three years persons over the age of 50 years undergo careful abdominal palpation aimed at detecting AAAs, as part of the periodic health examination. We further recommend that obese older men at high risk for AAA have at least one-time screening with abdominal ultrasound, regardless of findings on physical examination.

Fatal pulmonary emboli in hospitalized patients. An autopsy study.

Abstract: • To determine the accuracy of the antemortem diagnosis of major pulmonary embolism, we reviewed 1276 autopsy reports at St Michael's Hospital, Toronto, from 1980 to 1984. Of 44 patients identified with major pulmonary embolism as the cause of death or a major factor contributing to it, 14 (31.8%) had the diagnosis suspected before death. We could not find any distinctive features separating these patients from those in whom the diagnosis of pulmonary embolism was not suspected before death. We conclude that major pulmonary embolism is still underdiagnosed in hospitalized patients, despite the availability of lung scanning and pulmonary angiography. ( Arch Intern Med 1988;148:1425-1426)

Cortical function in elderly non-insulin dependent diabetic patients. Behavioral and electrophysiologic studies.

Abstract: • Neurobehavioral and electrophysiologic studies were carried out to determine the effect of diabetes mellitus on cognitive function in subjects over the age of 60 years. Forty-three non—insulin-dependent diabetic men were compared with 41 male nondiabetic age-matched controls. The diabetic patients were significantly inferior to the control group in the serial learning task and Benton's Visual Retention Test. The digit span test showed no difference between the groups. Electroencephalogram (EEG)-frequency-band analysis revealed slowing over the central cortex and reduction of α activity over the parietal area in diabetic patients. Acute hyperglycemia induced in healthy volunteers with the administration of 50 g of intravenous glucose did not have any effect on the dominant EEG rhythms. The checkerboard elicited P100 wave did not reveal a significant increase in latency nor were the P300 wave latencies significantly different in diabetic patients. However, a trend toward longer latencies in diabetics was evident at F z and C z recording sites. Acute hyperglycemia in healthy volunteers did not alter the P300 wave component. The results indicate that elderly type 2 diabetic patients have an impairment in retrieval of recently learned material with preservation of auditory attention and immediate recall. The EEG data suggest that there may be some central neural pathologic condition associated with diabetes. ( Arch Intern Med 1988;148:2369-2372)

Predicting life span for applicants to inpatient hospice.

Abstract: • The advent of hospice programs and their funding under Medicare has recently made eligibility for substantial insured services turn on whether a patient has less than three or six months to live. The implicit assumption is that physicians can provide this prediction accurately. To test this assumption and to improve predictions, the life spans of 108 consecutive applications for inpatient hospice care were estimated independently by two oncologists, an internist, an oncology nurse, and a hospice social worker, based on data in a ten-page multidisciplinary application packet. The applicants were followed up until death. Actual life span was correlated with predictions. The median (± SD) life span was 3.5 ± 12.4 weeks. The predictions as a group were overly optimistic about survival by an average of 3.4 weeks. The best prognosticator's prediction was only moderately correlated with actual life span, and no two prognosticators' predictions correlated closely with one another. Predicting actual interval until death was more accurate than predicting a 90% confidence interval around the time of death, though the latter procedure was better at avoiding the error of unpredicted long-term survivors. This imprecision in "expert" estimation of life span poses substantial problems for hospice programs and policymakers. ( Arch Intern Med 1988;148:2540-2543)

Graves' Disease: Influence of Age on Clinical Findings

Abstract: • To determine the influence of age on the signs and symptoms of hyperthyroidism we prospectively examined 880 patients and matched them by age, sex, race, and visit date with similarly examined euthyroid control subjects. Many signs and symptoms showed little change with age until after the fifth decade of life when they began to decrease gradually. Findings that increased with age were weight loss and atrial fibrillation, while those that decreased most markedly with age were increased appetite and weight gain. The diagnosis is more difficult as age progresses because there are fewer findings and because the significance of those present may not be appreciated. Identification of the most sensitive and specific signs and symptoms in each age decade should improve the early detection of hyperthyroidism. ( Arch Intern Med 1988;148:626-631)

Access to Kidney Transplantation: Has the United States Eliminated Income and Racial Differences?

Abstract: • We analyzed the effect of patient and dialysis unit characteristics on access to kidney transplantation using several different approaches, including an analysis of individual patient data from a systematic random sample of 2900 new dialysis patients from each year 1981 to 1985 (14721 patients total). Additional analyses focused on the composition of transplant waiting lists and aggregate data from a 1984 census of 1133 dialysis and transplant units. White, male, young, nondiabetic, high-income patients treated in smaller units are more likely to receive a cadaver transplant under Medicare than are other kidney patients. Profit status of the dialysis unit was not found to be correlated to access to transplantation, although size of the unit may be correlated to access. Future analysis should focus on whether patient access has been inappropriately compromised. Possible factors unexplored in this analysis include differential patient preferences and medical suitability, as well as differential medical access. (Arch Intern Med1988;748:2594-2600)

Prevention of Amphotericin B—Induced Renal Impairment: A Review on the Use of Sodium Supplementation

Abstract: • Amphotericin B is the treatment of choice for most deepseated mycoses; however, doses may have to be limited because of concern over adverse effects such as nephrotoxicity. Evolving evidence suggests that the extent of amphotericin B—induced renal impairment may be modified via alteration of a normal physiologic feedback response that further contributes to changes due to direct nephrotoxicity. As such, renal impairment has a substantial theoretically preventable and reversible element. In animals exposed to amphotericin B, sodium loading interferes with this response. Mounting clinical evidence also supports the usefulness of sodium supplementation to prevent as well as to reverse amphotericin B—induced nephrotoxicity. At this time, the use of sodium supplementation (eg, intravenous saline and/or ticarcillin disodium, which contains 5.2 mEq of sodium per gram of drug) along with avoiding dehydration appears to be a safe and effective means of reducing the risk of nephrotoxicity associated with amphotericin B administration; however, it is not known whether renal changes can be entirely prevented. These preliminary observations merit confirmation in a prospective, randomized clinical trial. (Arch Intern Med1988;148:2389-2394) The incidence of mycotic disease is increasing. A recent survey indicates that fungal organisms are isolated in from 1% to 12% of hospitalized patients, currently accounting for approximately 5% of all cases of primary septicemia.1The reason for this escalation in mycotic disease is the increased number of patients occupying hospital beds with risk factors for fungal infections. The major risk factor is impaired host defense mechanisms due to underlying disease (eg, acquired immunodeficiency syndrome) or therapeutic maneuvers (eg, cancer chemotherapy, radiotherapy, iatrogenic immunosuppression for organ transplantation). Despite the availability of newer antifungal agents, amphotericin B (Fungizone) remains the broad-spectrum antifungal antibiotic of choice for the treatment of deepseated mycotic infections. Unfortunately, this drug causes a variety of adverse effects, including fever, chills, nausea,

Early Metastatic Cancer of Unknown Primary Origin at Presentation: A Clinical Study of 302 Consecutive Autopsied Patients

Abstract: • We studied 302 consecutive autopsied patients who presented with carcinoma of unknown primary origin. The most frequent metastatic sites were the nodes, lung, and bone. The primary site was identified while patients were alive in 27% and at autopsy in 57%; the site remained unidentified in 16%. The pancreas (26.5%), lung (17.2%), kidney (4.6%), and colorectum (3.6%) were the most frequent primary sites, but the reliability of diagnostic tests used in the search for this site was disappointing. Survival was identical in patients whose primary site was discovered while alive, at autopsy, or remained unknown. The number of metastases at presentation was the major prognostic factor. Analysis of autopsy data demonstrated that patients with carcinoma of unknown primary origin pursue a different course than expected when the primary site is the first manifestation of the disease. On the basis of these results and the results of other modern series, we suggest an approach consisting of a limited initial workup but with greater emphasis on modern histochemistry studies and immunohistopathologic and other kinetic and morphologic parameters to understand the patient tumor characteristics better and base the clinical management on an individual basis. ( Arch Intern Med 1988;148:2035-2039)