Showing papers in "The New England Journal of Medicine in 1969"

Significance of the positive crossmatch test in kidney transplantation.

Abstract: Crossmatch tests of the prospective kidney-transplant donor's lymphocytes with the serum of the prospective recipient in 225 transplants showed that eight of 195 with negative crossmatch f...

Modification of Parkinsonism--chronic treatment with L-dopa.

Abstract: Slowly increasing oral doses of L-3,4-dihydroxyphenylalanine (L-dopa) induced at least partial improvement of some manifestations in a series of 28 patients with Parkinsonism. Improvement of performance was graded as modest in four, moderate in four, marked in 10 and dramatic in 10. This was usually sustained for periods up to two years. Evidence of toxicity was signaled by few of the variables monitored. Mental effects included enhanced interest, improved memory, transitory sleeplessness and nervousness. Nausea and vomiting were largely circumvented by slowing of the increases of the daily dose. A peripheral dopadecarboxylase inhibitor diminished the therapeutic dose of L-dopa required and eliminated anorexia and nausea in one case. Neurologic side effects consisted of involuntary movements ranging from fleeting to severe.

Gaps in doctor-patient communication. Patients' response to medical advice.

Abstract: Study of 800 outpatient visits to Childrens Hospital of Los Angeles to explore the effect of the verbal interaction between doctor and patient on patient satisfaction and follow-through on...

Changing pharyngeal bacterial flora of hospitalized patients. Emergence of Gram-negative bacilli.

Abstract: The prevalence of gram-negative bacilli among the oropharyngeal bacterial flora was low in physiologically normal subjects despite hospital exposure but rose markedly in patients with illnesses of varying severity. This increased prevalence was not correlated with antibiotic administration or inhalation therapy, was not dependent on duration of hospitalization and correlated best with the clinical severity of illness. Increased exposure to these organisms alone does not adequately explain these findings, suggesting that pharyngeal clearance mechanisms are impaired in these patients. Since most bacterial pneumonias begin with the aspiration into the lung of bacteria present in the upper respiratory tract, this alteration in the pharyngeal flora of ill patients may represent an important initial step in the pathogenesis of pneumonia due to gram-negative bacilli.

Determination of therapeutic and toxic serum digoxin concentrations by radioimmunoassay.

Abstract: A sensitive (0.2 ng per milliliter), precise (standard deviation 3 to 4 per cent), and specific radioimmunoassay for serum digoxin concentration has been developed. Levels are determined by measurement of the extent to which digoxin in the patient's serum competes with tritium-labeled digoxin, added in vitro, for digoxin-specific antibody binding sites. Mean values in nontoxic patients with normal renal function receiving 0.25 or 0.50 mg per day were 1.1 and 1.4 ng per milliliter respectively; the ranges fell within relatively narrow limits. Patients with cardiac arrhythmias attributed to digoxin toxicity had a mean level of 3.3 ng per milliliter, and little overlap with the nontoxic group (p less than 0.001). A determination can be completed in one hour, and may provide useful information to the clinician faced with the difficult problem of evaluating his patient's state of digitalization.

Plasma amino acid levels and insulin secretion in obesity.

Abstract: Of 20 plasma amino acids measured, valine, leucine, isoleucine, tyrosine and phenylalanine were increased, and glycine decreased, in obese subjects compared with age- and sex-matched controls The concentration of each of the amino acids elevated in obesity correlated directly with serum insulin In addition, these were the amino acids most sensitive to the action of insulin in lowering plasma amino acid levels, as evidenced by a diminution in concentration after glucose infusion Despite a significantly greater increment in serum insulin in the obese group, the magnitude of the decline in amino acids after glucose administration was identical in the two groups Hyperaminoacidemia appears to be a manifestation of the insulin ineffectiveness characteristic of obesity Furthermore, hyperaminoacidemia may provide the feedback signal to the beta cell through which insulin resistance is accompanied by an appropriately augmented secretory rate of insulin

Production and excretion of hydrogen gas in man.

Abstract: Technics employing intestinal infusions of gas were used to study H2 production in the human intestine. The volume of H2 in the bowel of 10 normal subjects varied from 0.06 to 29 ml. H2 production, which averaged 0.24 ml per minute in the fasting state, sharply increased after intestinal instillation of lactose to a mean peak rate of 1.6 ml per minute. Ingestion of food also increased H2 production by seven-fold to 30-fold. In the normal intestine, more than 99 per cent of H2 production was colonic, but small-bowel production was increased in a patient with excessive numbers of small-bowel bacteria. H2 production in man is primarily dependent upon the delivery of ingested, fermentable substrates to an abundant intestinal flora that normally is present only in the colon. A mean of 14 per cent of the total H2 production was excreted by the lungs, and rates of breath H2 excretion and H2 production correlated well (r = 0.94). Respiratory H2 excretion can therefore be used as an indicator of intestina...

Chronic eosinophilic pneumonia

Abstract: Nine women presented an unusual and distinctive syndrome consisting of a chronic and ultimately life-threatening illness with high fever, night sweats, weight loss and severe dyspnea. Tuberculosis was the initial diagnosis in most cases, but the patients' condition deteriorated on chemotherapy. Asthma occurred for the first time with the onset of the illness in six patients, whereas three had neither asthma nor blood eosinophilia. The roentgenograms showed characteristic, rapidly progressive, dense pneumonic infiltrates arranged in a peculiar peripheral pattern best described as a "photographic negative" of the shadows seen in pulmonary edema. Chronic eosinophilic pneumonia was recognized from the consistent pathological pattern of the lung biopsies. Corticosteroid therapy caused complete clinical recovery and clearing of the roentgenograms within a few days. With premature reduction or omission of therapy symptoms recurred, and the infiltrates reappeared precisely in the same locations. Long-ter...

Platelet transfusion therapy; the selection of compatible platelet donors for refractory patients by lymphocyte HL-A typing.

Abstract: Five patients with bone-marrow aplasia had become refractory to platelet transfusions from random donors. The response to platelets from available family members of each of the patients was then studied. Three patients had excellent responses to platelets from a single sibling, and two each responded to platelets from two siblings. The lymphocytes of the donors and recipients were typed for HL-A antigens by the lymphocyte cytotoxicity test. Genotypic analysis of the phenotypes revealed that the excellent responses occurred with platelets from HL-A identical siblings. The patient's serums exhibited no lymphocyte cytotoxicity against the respective seven HL-A identical siblings whereas cytotoxicity was demonstrated to nine of 11 HL-A nonidentical family members. Three patients have received 8 units of platelets per week for 11, 15, and 24 months from HL-A identical siblings without the development of cytotoxic antibodies. HL-A lymphocyte typing of family members can be used to predict platelet comp...

Complications of smallpox vaccination, 1968

Abstract: In 1968, 572 persons in the United States had confirmed vaccination complications. Of these, 82.5 per cent had received Vaccinia Immune Globulin. Sixty-eight per cent of the patients were primary vaccinees, 7 per cent were revaccinees, 20 per cent acquired vaccinia not by vaccination but by contact, and 5 per cent had unknown histories of vaccination. There were nine deaths: four caused by postvaccinial encephalitis, four associated with vaccinia necrosum, and one caused by eczema vaccinatum. There were 74 complications and one death per 1,000,000 primary vaccinations. Morbidity and mortality rates were highest for infants, with 112 complications and five deaths per 1,000,000 primary vaccinations. Eczema vaccinatum was more severe for contacts than for vaccinees. Although the risk with revaccination is less than a tenth that with primary vaccination, vaccinia necrosum develops in patients with immunologic disorders whether or not they have been previously vaccinated. These estimates, based on sur...

Acute Mountain Sickness

Abstract: Observations on acute mountain sickness occurring between 11,000 and 18,000 feet, in 1925 men, 18, to 53 years old, showed no direct relation between altitude and severity of illness; mild, moderate and severe cases occurred at all altitudes. A time lag of six to 96 hours between arrival and onset of symptoms ruled out any direct relation between hypoxia and acute mountain sickness. During this period there was clinical evidence of respiratory dysfunction with slow, irregular or Cheyne—Stokes breathing, pulmonary congestion and antidiuresis. In one biopsy and two autopsy studies there was evidence of cerebral edema. Diuresis induced with furosemide provided effective routine therapy. Morphine and betamethasone were used as additional aids in severe cases. Clinical features of acute mountain sickness were ascribed to hypoxia, pulmonary congestion, increased cerebral blood flow, increased cerebrospinal-fluid pressure and cerebral edema.

Measurement of Serum DNA-Binding Activity in Systemic Lupus Erythematosus

Abstract: Antibodies to DNA were demonstrated in the serums of patients with systemic lupus erythematosus (SLE) by ammonium sulfate precipitation. DNA is soluble in 50 per cent saturated ammonium sulfate, whereas immunoglobulins and immunoglobulin-bound DNA are insoluble. When ammonium sulfate is added to a mixture of radioactive DNA and serum, the precipitate contains radioactivity if DNA is bound to immunoglobulins. Abnormal binding was found in serum of 75 per cent of unselected patients with SLE, 25 per cent with Sjogren's syndrome, 5 per cent with related disease and 2 per cent of normal subjects. All of 52 selected SLE serums with positive, as well as 21 of 32 SLE serums with negative, complement-fixation tests for anti-DNA antibodies had abnormal binding. Binding activity was associated with immunoglobulin G of serum. High binding values were seen chiefly in patients with active SLE renal disease; marked reductions accompanied clinical improvement. The test overcomes problems inherent in other metho...

Course and prognosis of chronic obstructive lung disease. A prospective study of 200 patients.

Abstract: To document the course and prognosis of chronic obstructive lung disease, 200 patients with the disorder were enrolled in a prospective standardized study four to eight years ago. Their disease progressed in a more regular and more predictable fashion than had been anticipated from casual clinical observations. Reasonably precise predictions of longevity could be made on the basis of initial findings. Measurements of ventilatory capacity, resting heart rate and carbon dioxide levels were the best indicators of prognosis. Prediction of survival was further improved by consideration of the course of physiologic abnormalities over a two-year follow-up period. Most features of the disease showed a systematic tendency to worsen, but yearly changes were relatively small, often becoming evident only with long-term observation. Data are compatible with the concept that chronic obstructive lung disease is a slowly progressive disorder that begins many years before the onset of clinical symptoms.

Cardiovascular Response to Large Doses of Intravenous Morphine in Man

Abstract: Large doses of intravenous morphine (0.5 to 3.0 mg per kilogram of body weight) were used alone or in combination with inhalation anesthetic agents for anesthesia in over 1100 patients undergoing open-heart surgery. Morphine, 1 mg per kilogram, was administered intravenously to seven subjects with aortic-valve disease and eight without major heart or lung disease. The cardiac subjects had higher control pulse rates and lower control stroke indexes than the normal subjects. In the cardiac but not in the normal subjects, significant increases in cardiac index, stroke index, central venous pressure, and pulmonary-artery pressure, and a significant decrease in systemic vascular resistance, were observed after morphine was administered, suggesting that large doses of morphine may be used with safety in patients with minimal circulatory reserve.

Hypertension in End-Stage Renal Disease

Abstract: Two distinct patterns of response of blood pressure to achievement of dry weight (no clinical evidence of edema and optimal body sodium content and volume of water), antihypertensive drugs and bilateral nephrectomy were documented in 40 unselected patients with end-stage renal disease. Group 1, 35 of 40 patients, was characterized by an excellent response of blood pressure to dry weight and the ability to remain normotensive without antihypertensive drugs as long as dry weight was maintained. Group 2, five of 40 patients, had persistent hypertension in spite of dry weight, a poor response to antihypertensive drugs and a prompt reduction of blood pressure after bilateral nephrectomy. A further important difference between these two groups was seen in the serum renin values obtained at the initiation of therapy. In Group 1 values ranged from 0 to 1.02 Goldblatt units × 10–4 per milliliter of serum (mean, 0.31) whereas those in Group 2 ranged from 1.88 to 4.60 (mean of 3.37 units). Serum renin level...

Functional asplenia in sickle-cell anemia.

Abstract: Observation of Howell—Jolly bodies in the blood of children with sickle-cell anemia suggested the paradox of splenic hypofunction despite clinical splenomegaly. Spleen scans were performed with a sulfur colloid tagged with radioactive technetium (99mTc). No splenic uptake of the colloid was seen in 11 of 12 children with sickle-cell anemia, although many had enlarged spleens. Twenty-five controls, including children with sickle-cell trait and Hgb SC and Hgb S-β thalassemia diseases, regularly demonstrated splenic uptake. Functional asplenia in children with sickle-cell anemia may be a pertinent factor in the susceptibility to infections — particularly pneumococcal infections — that is characteristic of this disease.

Serum Lipids in Infection

Abstract: Striking elevations in concentrations of total serum lipids were observed in patients with infection caused by gram-negative bacilli. The elevated levels of total lipid in these patients were due mainly to marked increases in serum concentrations of triglycerides or free fatty acids or both. In contrast, patients with severe infection caused by gram-positive cocci had normal concentrations of total serum lipids. Those with fever but no infection and those with influenza had normal concentrations of total serum lipids and normal levels of the major lipid classes. Patients with infectious or serum hepatitis demonstrated a moderate hyperlipidemia, which resulted from increased concentrations of serum triglycerides and free cholesterol. Lipoprotein electrophoresis demonstrated that the hyperlipidemia in patients with severe infection caused by gram-negative bacilli was related to increased levels of pre-beta-lipoproteins. In patients with hepatitis there were increased levels of pre-beta-lipoproteins...

Age at Menarche

Abstract: CLINICIANS are often asked by concerned parents whether their daughter's age at menarche is abnormally late — or abnormally early In answer, it may be said that what is normal for a particular girl depends upon her genes and life history as well as the common characteristic of human females to start to menstruate at sometime during the second decade of life For each species of mammal, a characteristic period elapses between birth and the development of full sexual function In normal girls evidence of sexual maturation characteristically appears not at four or 40, but at eight or 10 or

Isolation of Measles Virus from Cell Cultures of Brain from a Patient with Subacute Sclerosing Panencephalitis

Abstract: Isolation of measles virus from the brain of a patient with subacute sclerosing panencephalitis was accomplished by in vitro propagation of the patient's brain cells and cocultivation of the brain cells with a line of green-monkey-kidney cells. This observation offers direct evidence that measles virus has a a role in the etiology of the disease. Before the production of detectable, mature virus by the cell cultures, there was a prolonged period when they produced syncytia containing measles antigen, but they failed to hemadsorb.

Skeletal Renewal and Metabolic Bone Disease

Abstract: Control of Skeletal Remodeling From the point of view of control mechanics, remodeling exhibits two control loops with negative feedback characteristics: parathyroid-calcitonin-mediated resorption,...

Resolution Rate of Acute Pulmonary Embolism in Man

Abstract: In 15 patients with definite angiographic evidence of embolism involving both lungs, and treated with heparin or venous ligation or both, sequential studies showed only minimal angiographic and hemodynamic signs of resolution at seven days. By 10 to 21 days, pressures in the right side of the heart had decreased to near normal levels, and there was unmistakable angiographic evidence of resolution. Complete resolution, with normal angiograms and hemodynamics, was noted in three patients at 14, 15 and 34 days. In other patients angiographic and hemodynamic abnormalities persisted weeks after embolism.

Effect of Antibiotic Therapy in Acute Salmonellosis on the Fecal Excretion of Salmonellae

Abstract: Treatment of patients with acute salmonella gastroenteritis with either chloramphenicol or ampicillin prolonged the period of postconvalescent excretion of salmonellae. Of 185 patients treated with antibiotics, 65.4 per cent were still positive for Salmonella typhimurium 12 days after exposure, and 27.0 per cent were positive at 31 days. In contrast, of 87 who were not treated, only 42.5 per cent and 11.5 per cent were positive at 12 and 31 days, respectively. Therapy also favored the in vivo acquisition of antibiotic resistance by the infecting strain, which was initially susceptible to multiple antibiotics. Salmonella strains resistant to one or more antibiotics were isolated from 9.7 per cent of patients treated with antibiotics, whereas no resistant strains were obtained from untreated patients. Resistance transfer factor was demonstrated in nine of 12 strains with acquired multiple resistances that were studied. Thus, antibiotic therapy increases the opportunity not only for person-to-person...

Changing staphylococci and staphylococcal infections. A ten-year study of bacteria and cases of bacteremia.

Abstract: Clinical and bacteriologic findings in about 2000 cases of bacteremia illustrate the changes within the staphylococcal flora in Danish hospitals during the years 1957–66. The phage type complex 52, 52A, 80, 81, usually resistant to penicillin and streptomycin only, regressed with the increasing use of newer antibiotics. It was succeeded by a series of mutually related types of phage Group III, in which resistance to several antibiotics was acquired concomitantly with a stepwise blocking of susceptibility to phage, probably owing to "epidemic" phage activity. The latest members of the series were often methicillin resistant. The combined effects of lysogenization, transduction and selection affect not only phage type and antibiotic resistance but also properties more directly connected with pathogenicity, such as lipase production, which facilitates the development of boils, and enhances mortality in cases of bacteremia. Development of new staphylococcal types is accelerated in hospitals by abunda...

Cholestyramine treatment of diarrhea associated with ileal resection.

Abstract: The efficacy of cholestyramine as treatment for diarrhea in patients with ileal resection was examined by inpatient and outpatient trials. Ten of 12 patients having less than 100 cm of distal ileum resected and some remaining ascending colon responded to cholestyramine, 16 gm per day, by a significant decrease in fecal frequency or fecal weight or both. By contrast, none of eight patients having resections of more than 100 cm of ileum responded. The degree of steatorrhea was also of predictive value since all eight patients with fecal fat excretion less than 20 gm per day responded, whereas none of five patients with greater steatorrhea responded. Cholestyramine is useful symptomatic treatment for diarrhea in patients with small ileal resections and mild steatorrhea. The response may be further evidence that diarrhea in these patients is caused by bile acid malabsorption resulting in increased passage of bile acids into the colon, where they induce secretion of salt and water.

Relation of Australia-SH antigen to the willowbrook MS-2 strain.

Abstract: surprisingly poor quality; the author admits freely (p. 38) that the purpose of his taking photographs was \". . . the best way for me to create an aura of respectability.\" The pictures are poorly composed, badly focused, and quite uninteresting. The text which accompanies them becomes comical at times in its overinterpretation, as in his description of \"an altogether private look\" given by a new mother to her husband. The picture in question shows the woman's blurry profile and her husband cropped off at the shoulders (pp. 70-71). There are many other books available with excellent photographs and less turgid writing. But there would still be a justification for this book if it were the honest exploration of a man's emotional feelings about childbirth and fatherhood, in which case one would expect to hear about the emotions connected with personal experience. Remarkably, the author is not writing about the birth of his own children, though he mentions just in passing that he has three children of his own. Rather, he diligently records his own feelings about being at the births of three infants whose parents do not know him well but allow him to be present. His decision to do this project came, apparently, as a result of his artistic difficulties with his \"Cycle of Life\" sculpture. The situation seems somewhat irrelevant. The writing is wholly subjective, even self-indulgent, and the few opinions expressed, on the use of drugs during labor, silver nitrate treatment for infants' eyes, and the separation of mother and infant after birth, are confused and misinformed. The fact that some combination of these practices occurred with each birth compromises his advocacy of \"natural\" childbirth considerably. In short, this book does not succeed at all and should not be recommended. There are too many other visually satisfying and informative books available on the new practice of childbirth.

Hepatic Bilirubin UDP-Glucuronyl Transferase Activity in Liver Disease and Gilbert's Syndrome

Abstract: A recently described method for assaying the specific hepatic enzyme responsible for the conjugation of bilirubin was applied to specimens of liver obtained at laparotomy or by percutaneou...

Transplantation of cadaveric kidneys from patients with hepatorenal syndrome. Evidence for the functionalnature of renal failure in advanced liver disease.

Abstract: A kidney from each of five patients and both kidneys from a sixth patient dying with the hepatorenal syndrome (severe hepatic failure, oliguria, azotemia, hyponatremia and a urinary sodium of less than 5 mEq per day) were transplanted into seven patients with end-stage kidney disease whose liver function was normal. Diuresis and improvement of renal function occurred in all but one recipient. Because of postoperative complications, two kidneys were removed after diuresis had occurred. Four transplanted kidneys achieved stable function for six months or longer, with creatinine clearances of 25, 42, 50 and 52 ml per minute. The hepatorenal syndrome is functional and potentially reversible.