Showing papers in "The New England Journal of Medicine in 1982"

Epidemiologic features of chronic atrial fibrillation: the Framingham study.

Abstract: In the Framingham Study 2325 men and 2866 women 30 to 62 years old at entry were followed biennially over 22 years for the development of chronic atrial fibrillation in relation to antecedent cardiovascular disease and risk factors. During surveillance, atrial fibrillation developed in 49 men and 49 women. The incidence rose sharply with age but did not differ significantly between the sexes. Overall, there was a 2.0 per cent chance that the disorder would develop in two decades. Atrial fibrillation usually followed the development of overt cardiovascular disease. Only 18 men and 12 women (31 per cent) had chronic atrial fibrillation in the absence of cardiovascular disease. Cardiac failure and rheumatic heart disease were the most powerful predictive precursors, with relative risks in excess of sixfold. Hypertensive cardiovascular disease was the most common antecedent disease, largely because of its frequency in the general population. Among the risk factors for cardiovascular disease, diabetes and electrocardiographic evidence of left ventricular hypertrophy were related to the occurrence of atrial fibrillation. The development of chronic atrial fibrillation was associated with a doubling of overall mortality and of mortality from cardiovascular disease.

The nature of suffering and the goals of medicine.

Abstract: The question of suffering and its relation to organic illness has rarely been addressed in the medical literature. This article offers a description of the nature and causes of suffering in patients undergoing medical treatment. A distinction based on clinical observations is made between suffering and physical distress. Suffering is experienced by persons, not merely by bodies, and has its source in challenges that threaten the intactness of the person as a complex social and psychological entity. Suffering can include physical pain but is by no means limited to it. The relief of suffering and the cure of disease must be seen as twin obligations of a medical profession that is truly dedicated to the care of the sick. Physicians' failure to understand the nature of suffering can result in medical intervention that (though technically adequate) not only fails to relieve suffering but becomes a source of suffering itself.

Decreased catecholamine sensitivity and beta-adrenergic-receptor density in failing human hearts.

Abstract: To identify the role of the myocardial beta-adrenergic pathway in congestive heart failure, we examined beta-adrenergic-receptor density, adenylate cyclase and creatine kinase activities, muscle contraction in vitro, and myocardial contractile protein levels in the left ventricles of failing and normally functioning hearts from cardiac-transplant recipients or prospective donors. Eleven failing left ventricles had a 50 to 56 per cent reduction in beta-receptor density, a 45 per cent reduction in maximal isoproterenol-mediated adenylate cyclase stimulation, and a 54 to 73 per cent reduction in maximal isoproterenol-stimulated muscle contraction, as compared with six normally functioning ventricles (P less than 0.05 for each comparison). In contrast, cytoplasmic creatine kinase activity, adenylate cyclase activities stimulated by fluoride ion and by histamine, histamine-stimulated muscle contraction, and levels of contractile protein were not different in the two groups (P less than 0.05). We conclude that in failing human hearts a decrease in beta-receptor density leads to subsensitivity of the beta-adrenergic pathway and decreased beta-agonist-stimulated muscle contraction. Regulation of beta-adrenergic receptors may be an important variable in cardiac failure.

Dietary Protein Intake and the Progressive Nature of Kidney Disease: The Role of Hemodynamically Mediated Glomerular Injury in the Pathogenesis of Progressive Glomerular Sclerosis in Aging, Renal Ablation, and Intrinsic Renal Disease

Abstract: IT is now more than 30 years since Addis suggested that protein intake be restricted in patients with chronic renal insufficiency.1 His aim was not to reduce uremic symptoms but rather to prevent a...

On the Elicitation of Preferences for Alternative Therapies

Abstract: We investigated how variations in the way information is presented to patients influence their choices between alternative therapies. Data were presented summarizing the results of surgery and radiation therapy for lung cancer to 238 ambulatory patients with different chronic medical conditions and to 491 graduate students and 424 physicians. We asked the subjects to imagine that they had lung cancer and to choose between the two therapies on the basis of both cumulative probabilities and life-expectancy data. Different groups of respondents received input data that differed only in whether or not the treatments were identified and whether the outcomes were framed in terms of the probability of living or the probability of dying. In all three populations, the attractiveness of surgery, relative to radiation therapy, was substantially greater when the treatments were identified rather than unidentified, when the information consisted of life expectancy rather than cumulative probability, and when the problem was framed in terms of the probability of living rather than in terms of the probability of dying. We suggest that an awareness of these effects among physicians and patients could help reduce bias and improve the quality of medical decision making.

Internist-I, an Experimental Computer-Based Diagnostic Consultant for General Internal Medicine

Abstract: INTERNIST-I is an experimental computer program capable of making multiple and complex diagnoses in internal medicine. It differs from most other programs for computer-assisted diagnosis in the generality of its approach and the size and diversity of its knowledge base. To document the strengths and weaknesses of the program we performed a systematic evaluation of the capabilities of INTERNIST-I. Its performance on a series of 19 clinicopathological exercises (Case Records of the Massachusetts General Hospital) published in the Journal appeared qualitatively similar to that of the hospital clinicians but inferior to that of the case discussants. The evaluation demonstrated that the present form of the program is not sufficiently reliable for clinical applications. Specific deficiencies that must be overcome include the program’s inability to reason anatomically or temporally, its inability to construct differential diagnoses spanning multiple problem areas, its occasional attribution of findings to improper causes, and its inability to explain its “thinking.” (N Engl J Med. 1982; 307:468–76.

Unusually large plasma factor VIII:von Willebrand factor multimers in chronic relapsing thrombotic thrombocytopenic purpura.

Abstract: A platelet-agglutinating factor has been detected in the plasma of some patients during episodes of thrombotic thrombocytopenic purpura (TTP).1 , 2 Agglutination induced in vitro by this plasma fac...

Treatment of B-Cell Lymphoma with Monoclonal Anti-Idiotype Antibody

Abstract: HUMAN B-cell malignant tumors result from the proliferation of single clones of cells that express surface markers characteristic of normal B lymphocytes.1 , 2 In particular, the surface immunoglobulin expressed by these cells is monoclonal — i.e., restricted to a single light-chain type and to a particular variable region unique to each case. The unique immunoglobulin variable region (idiotype) of each lymphoma clone may be considered a tumor-specific marker, distinguishing tumor cells from normal cells in the patient. We and others have shown that anti-idiotype antibodies can be used to monitor B-cell tumors and to investigate the biology of these tumors.3 4 5 Because . . .

Treatment of Gram-Negative Bacteremia and Shock with Human Antiserum to a Mutant Escherichia coli

Abstract: In an effort to decrease deaths from gram-negative bacteremia and endotoxin shock, we treated bacteremic patients with human antiserum to endotoxin (lipopolysaccharide) core. Antiserum was prepared by vaccinating healthy men with heat-killed Escherichia coli J5; this mutant lacks lipopolysaccharide oligosaccharide side chains, so that the core, which is nearly identical to that of most other gram-negative bacteria, is exposed for antibody formation. In a randomized controlled trial, patients were given either J5 antiserum or preimmune control serum intravenously, near the onset of illness. The number of deaths in the bacteremic patients was 42 of 109 (39 per cent) in controls and 23 of 103 (22 per cent) in recipients of J5 antiserum (P = 0.011). In those with profound shock, mortality was 30 of 39 (77 per cent) in controls and 18 of 41 (44 per cent) in recipients of J5 antiserum (P = 0.003). We conclude that human antiserum to the lipopolysaccharide core can substantially reduce deaths from gram-negative bacteremia.

Mechanisms of Gastroesophageal Reflux in Patients With Reflux Esophagitis

Abstract: We evaluated the mechanisms of gastroesophageal reflux in 10 patients with reflux esophagitis and compared the results with findings from 10 controls. The patients had more episodes of reflux (35 +/- 15 in 12 hours, as compared with 9 +/- 8 in the controls) and a lower pressure of the lower esophageal sphincter (13 +/- 8 mm Hg as compared with 29 +/- 9 in the controls) (P less than 0.001). Reflux occurred by three different mechanisms: transient complete relaxation of the lower esophageal sphincter, a transient increase in intra-abdominal pressure, or spontaneous free reflux associated with a low resting pressure of the lower esophageal sphincter. In controls 94 per cent of reflux episodes were caused by transient sphincter sphincter relaxation. In the patients 65 per cent of episodes of reflux accompanied transient sphincter relaxation, 17 per cent accompanied a transient increase in intra-abdominal pressure, and 18 per cent occurred as spontaneous free reflux. The predominant reflux mechanism in individual patients varied: some had normal resting sphincter pressure and reflux that occurred primarily during transient sphincter relaxation, whereas others with low resting sphincter pressures had spontaneous free reflux or reflux that occurred during an increase in intra-abdominal pressure.

Nutritional assessment: A comparison of clinical judgement and objective measurements

Abstract: The nutritional status of 59 randomly-selected general surgical ward patients (38 men, 21 women; mean age, 50.4 years) was studied (using both clinical assessment and objective analysis methods) to measure the reproducibility and validity of clinical assessment. Objective nutritional assessment included anthropometric and other (e.g., serum albumin, lymphocyte count, total-body nitrogen) measurements. Clinical status was assessed (history taking and physical exam) by 2 physicians before surgery. Clinical assessment reproducibility between the 2 physicians was demonstrated by independent agreement on clinical classification of 48 of the patients (81%). Validity was demonstrated by correlation of clinical classification with objective measurement of nutritional status; and with 3 measures of hospital morbidity (infection incidence, antibiotic use, and length of hospital stay). It is concluded that clinical assessment is reproducible and valid since it correlated well with objective measurements and morbidity. (wz)

Small-Area Variations in the Use of Common Surgical Procedures: An International Comparison of New England, England, and Norway

Abstract: We examined the incidence of seven common surgical procedures in seven hospital service areas in southern Norway, in 21 districts in the West Midlands of the United Kingdom, and in the 18 most heavily populated hospital service areas in Vermont, Maine, and Rhode Island. Although surgical rates were higher in the New England states than in the United Kingdom or Norway, there was no greater degree of variability in the rates of surgery among the service areas within the three New England states. Hernia repair was more variable in England (P less than 0.05) and hysterectomy in Norway (P less than 0.05) than in the other countries. There was consistency among countries in the rank order of variability for most procedures: tonsillectomy, hemorrhoidectomy, hysterectomy, and prostatectomy varied more from area to area than did appendectomy, hernia repair, or cholecystectomy. The degree of variation generally appeared to be more characteristic of the procedure than of the country in which it was performed. Thus, differences among countries in the methods of organizing and financing care appear to have little relation to the intrinsic variability in the incidence of common surgical procedures among hospital service areas in these countries. Despite the differences in average rates of use, the degrees of controversy and uncertainty concerning the indications for these procedures seem to be similar among clinicians in all three countries.

Different intensities of oral anticoagulant therapy in the treatment of proximal-vein thrombosis.

Abstract: We have previously reported that long-term therapy with warfarin is effective for preventing recurrent venous thromboembolism in patients with proximal-vein thrombosis but that there is an appreciable risk of hemorrhage. To determine whether that risk could be reduced without a loss of effectiveness, we randomly allocated 96 patients with proximal-vein thrombosis to a group receiving less intense anticoagulant therapy, with a mean prothrombin time of 26.9 seconds using the Manchester comparative reagent (corresponding Simplastin time, 15 seconds), or a group given more intense therapy, with a mean Simplastin time of 19.4 seconds (corresponding prothrombin time 41 seconds with the Manchester comparative reagent) (P less than 0.001). Two of 47 patients (4 per cent) in the less intensely treated group had hemorrhagic complications, as compared with 11 of 49 patients (22 per cent) in the more intensely anticoagulated group (P = 0.015 by the two-tailed test). This difference was due to minor bleeding episodes. The frequency of recurrent venous thromboembolism was low in both groups (2 per cent). Our findings indicate that less intense anticoagulant therapy is associated with a low frequency of recurrent venous thromboembolism (2 per cent) and a reduced risk of hemorrhage.

Catheter Technique for Closed-Chest Ablation of the Atrioventricular Conduction System

Abstract: This report describes a catheter technique for ablating the His bundle and its application in nine patients with recurrent supraventricular tachycardia that was unresponsive to medical management. A tripolar electrode catheter was positioned in the region of the His bundle, and the electrode recording a large unipolar His-bundle potential was identified. In the first patient, two shocks of 25 and 50 J, respectively, were delivered by a standard cardioversion unit to the catheter electrode, resulting in an intra-His-bundle conduction defect. Subsequent delivery of 300 J resulted in complete heart block. In the next eight patients, an initial shock of 200 J was used. The His bundle was ablated by this single shock in six of these patients and by an additional shock of 300 J in one. In the remaining patient, conduction in the atrioventricular node was modified, resulting in alternating first and second-degree atrioventricular block. A stable escape rhythm was preserved in all patients. The procedure was well tolerated, without complications, and all patients have remained free of arrhythmia, without medication, for follow-up periods of two to six months.

Mechanism of Action of Calcium-Channel-Blocking Agents

Abstract: Calcium ions (Ca++) are vital in many biologic processes, including a variety of enzymatic reactions, activation of excitable cells, coupling of electrical activation to cellular secretion, hemostasis, and the metabolism of bone. The development of drugs that interfere with the entry of Ca++ into cells — variously termed Ca++-channel blockers, Ca++-entry blockers, Ca++ antagonists, and slow-channel blockers — has provided the basic scientist with powerful new tools for the study of the role of this ion in normal as well as pathologic states and has provided the clinician with several important new therapeutic agents for use in . . .

Transient reversal of thrombocytopenia in idiopathic thrombocytopenic purpura by high-dose intravenous gamma globulin

Abstract: Since recent observations indicate that treatment with high-dose intravenous polyvalent intact immunoglobulin leads to a rapid reversal of thrombocytopenia in the idiopathic thrombocytopenic purpura (ITP) of childhood, we decided to apply this treatment to adults with ITP and to test the possibility that the effect of the immunoglobulin might be attributable to transient blockade of the reticuloendothelial system. Using sequential clearance studies of autologous 99mTc-labeled and anti-Rh(D)-sensitized erythrocytes in four adults with ITP who were treated with total doses of 1 to 1.5 g of immunoglobulin per kilogram of body weight, we found that a transient rise in platelet counts to normal levels within four to five days was accompanied by a marked temporary prolongation of the immune-particle clearance time. These data suggest that commercial intravenous immunoglobulin preparations may interfere with phagocyte Fc-receptor-mediated immune clearance. Since platelets in ITP treated with immunoglobulin were fully hemostatic, this type of therapy may allow surgical procedures to be performed safely in patients with this disease.

Diagnosis of Coliform Infection in Acutely Dysuric Women

Abstract: We reevaluated conventional criteria for diagnosing coliform infection of the lower urinary tract in symptomatic women by obtaining cultures of the urethra, vagina, midstream urine, and bladder urine. The traditional diagnostic criterion, greater than or equal to 10(5) bacteria per milliliter of midstream urine, identified only 51 per cent of women whose bladder urine contained coliformis. We found the best diagnostic criterion to be greater than or equal to 10(2) bacteria per milliliter (sensitivity, 0.95; specificity, 0.85). Although isolation of less than 10(5) coliforms per milliliter of midstream urine has had a low predictive value of previous studies of asymptomatic women, the predictive value of the criterion of greater than or equal to 10(2) per milliliter was high (0.88) among symptomatic women the prevalence of coliform infection exceeded 50 per cent. In view of these findings, clinicians and microbiologists should alter their approach to the diagnosis and treatment of women with acute symptomatic coliform infection of the lower urinary tract.

Heart-lung transplantation: successful therapy for patients with pulmonary vascular disease.

Abstract: We report our initial experience with three patients who received heart-lung transplants The primary immunosuppressive agent used was cyclosporin A, although conventional drugs were also administered In the first patient, a 45-year-old woman with primary pulmonary hypertension, acute rejection of the transplant was diagnosed 10 and 25 days after surgery but was treated successfully; this patient still had normal exercise tolerance 10 months late The second patient, a 30-year-old man, underwent transplantation for Eisenmenger's syndrome due to atrial and ventricular septal defects His graft was not rejected, and his condition was markedly improved eight months after surgery The third patient, a 29-year-old woman with transposition of the great vessels and associated defects, died four days postoperatively of renal, hepatic, and pulmonary complications We attribute our success to experience with heart-lung transplantation in primates, to the use of cyclosporin A, and to the anatomic and physiologic advantages of combined heart-lung replacement We hope that such transplants may ultimately provide an improved outlook for selected terminally ill patients with pulmonary vascular disease and certain other intractable cardiopulmonary disorders

Percutaneous balloon valvuloplasty: a new method for treating congenital pulmonary-valve stenosis.

Abstract: TRANSLUMINAL balloon angioplasty has been increasingly accepted as a nonsurgical technique for dilatation of stenotic arteries in the peripheral, renal, and coronary circulations.1 2 3 4 5 6 The ph...

Congenital cytomegalovirus infection: The relative importance of primary and recurrent maternal infection.

Abstract: We studied the incidence of primary and recurrent cytomegalovirus infection in 3712 pregnant women--2698 of middle to high income and 1014 of low income--to determine whether there were differences in the effects on the fetus. In the higher-income group, 1203 women (45 per cent) did not have antibodies to cytomegalovirus and were therefore susceptible to primary infection, as compared with 179 women (18 per cent) of low income. Congenital infection occurred more often (1.6 vs. 0.6 per cent) in infants in the low-income group. In this group it was associated with recurrent maternal infection more often (in 82 per cent) than with primary maternal infection, whereas in the upper-income group, it was associated with primary maternal infection in half the cases. Altogether, there were 32 cases of congenital cytomegalovirus infection - 16 in each group. Whereas primary maternal infection resulted in fetal infection in only half the cases, it was more likely to ge associated with clinically apparent disease than was recurrent infection. When these cases were combined with 28 cases of congenital infection retrospectively identified at other prenatal clinics, five of 33 infected infants born after primary maternal infection had clinically apparent disease, as compared with none of 27 born after recurrent maternal infection. We conclude that congenital cytomegalovirus infection resulting from primary maternal infection is more likely to be serious than that resulting from recurrent infection, and is more likely to occur in upper socioeconomic groups.

Incidence of radiographically evident bone disease, nephrocalcinosis, and nephrolithiasis in various types of renal tubular acidosis.

Abstract: The syndrome of renal tubular acidosis has been categorized into three physiologic types that have different clinical findings and prognostic and therapeutic implications. We reviewed radiographs of the skeleton and kidneys in 92 patients (56 children and 36 adults) with renal tubular acidosis in order to determine whether the radiologic findings could be related to the type of syndrome. Forty-four patients had Type 1 renal tubular acidosis, 18 had Type 2, and 30 had Type 4. Evidence of skeletal abnormalities was uncommon (17 per cent) and was confined to patients who had the Type 2 disorder or azotemia. The children with Type 2 and skeletal abnormalities had rickets; the adults had osteopenia without pseudofractures. Nephrocalcinosis was evident in approxiately one fourth of the group (29 per cent) and was restricted to patients with the Type 1 syndrome. In patients with Type 4, osteopenia was evident in 12 per cent, all of whom were azotemic. Our observations indicate that the radiographic mani...

Distinctive Chromosomal Abnormalities in Histologic Subtypes of Non-Hodgkin's Lymphoma

Abstract: Using a new high-resolution technique for chromosomal analysis, we have successfully studied biopsy specimens of lymph nodes from 42 of 44 patients with non-Hodgkin's lymphoma and have categorized them using the new international histologic formulation and immunologic markers. Abnormalities of the clonal chromosomes were detected in all 42 patients. Three recurrent chromosomal aberrations were found to correlate with certain histologic types: a translocation between chromosomes 18 and 14 in 16 of 19 patients with follicular lymphomas (small cleaved cell, mixed cell, and large cell); a translocation between chromosomes 8 and 14 in 5 of 6 patients with small noncleaved-cell (non-Burkitt's) or large-cell immunoblastic lymphoma; and a trisomy 12 in 4 of 11 patients with small-cell lymphocytic lymphoma. Our findings suggest that characteristic chromosomal defects occur in certain lymphoma subtypes and that high-resolution chromosomal analysis promises to become an important tool in improving our basic understanding of lymphoid cancers.

Thyrotropin-releasing hormone

Abstract: The modern era of neuroendocrinology was ushered in just over a decade ago with the isolation and characterization, from ovine1 and porcine2 hypothalamic tissue, of a tripeptide (pyroglutamyl-histi...

The respiratory muscles.

Abstract: THE respiratory system consists essentially of two parts: a gas-exchanging organ — the lungs—and a pump that ventilates the lungs. The pump consists of the chest wall, the respiratory muscles that ...

Cytotoxic t cells in cytomegalovirus infection: HLA-restricted T-lymphocyte and non-T-lymphocyte cytotoxic responses correlate with recovery from cytomegalovirus infection in bone-marrow-transplant recipients.

Abstract: We studied 58 recipients of bone-marrow transplants to evaluate immune responses to cytomegalovirus infection. Such infection developed in 43 patients; it was fatal in 12, nonfatal in 23, and present at death from other causes in eight. All patients had low or absent cytomegalovirus-specific cytotoxic lymphocyte activity before the onset of infection. Cytomegalovirus-specific cytotoxic responses developed in all survivors, whereas only two patients with fatal infection had even low-level cytomegalovirus-specific cytotoxic responses. Natural and antibody-dependent killer-cell activities were depressed both before and during infection in patients with fatal infections, but not in those who survived. The outcome of the infection did not correlate with the nature of the underlying disease, the type of transplant received, the pretransplantation cytomegalovirus-antibody status, or lymphocyte-proliferation responses to cytomegalovirus antigens or concanavalin A. The correlation between effective virus-specific cytotoxic response and recovery from infection indicates that these effector cells probably mediate recovery from cytomegalovirus infection.

Family management in the prevention of exacerbations of schizophrenia: a controlled study.

Abstract: Environmental stress has been implicated as an important factor in the relapse of schizophrenic patients receiving optimal drug therapy. In a randomized controlled study, we compared at-home family therapy with clinic-based individual supportive care in the community management of schizophrenia in 36 patients taking neuroleptic maintenance medications. The family-treatment approach sought to enhance the stress-reducing capacity of the patient and his or her family through improved understanding of the illness and training in behavioral methods of problem solving. The results at the end of nine months revealed the superiority of this approach in preventing major symptomatic exacerbations. Only one family-treated patient (6 per cent of all patients) was judged to have had a clinical relapse, as compared with eight patients (44 per cent) treated individually. Family-treated patients averaged 0.83 days in the hospital, as compared with 8.39 days for the comparison group. Significantly lower levels of schizophrenic symptomatology on blind rating-scale assessments supported these clinical observations of the superiority of family management.

Induction of Pemphigus in Neonatal Mice by Passive Transfer of IgG from Patients with the Disease

Abstract: We examined the role of circulating autoantibodies in the pathogenesis of pemphigus vulgaris by passively transferring IgG fractions from five patients with pemphigus vulgaris into neonatal Balb/c mice, in doses of 1.5 to 16 mg per gram of body weight per day. Cutaneous blisters and erosions with the histologic, ultrastructural, and immunofluorescence features of pemphigus occurred in 39 to 55 mice given intraperitoneal injections of IgG from patients with pemphigus and in none of 58 control mice given normal human IgG. IgG fractions with high titers of pemphigus antibodies were most effective in inducing disease, and this effect was dose dependent. Titers of circulating IgG in mouse serum closely correlated with the extent of disease induced (P less than 0.002). This study strongly supports the proposed role of pemphigus autoantibodies in the pathogenesis of pemphigus vulgaris in human beings and demonstrates that pemphigus can be passively transferred to laboratory animals.

Respiratory syncytial viral infection in infants with congenital heart disease.

Abstract: Occasional reports have suggested that infants with congenital heart disease may have an increased risk of severe illness from respiratory syncytial virus (RSV) infection. We prospectively studied 699 infants hospitalized during the winters of 1976 through 1980, when RSV was prevalent in the community; 229 of these infants had proved RSV infections acquired either before admission or during hospitalization; 27 had both congenital heart disease and RSV infection, and 46 had congenital heart disease without RSV infection. Infected infants with congenital heart disease had significantly more severe illness than those without congenital heart disease, as judged by the requirement for intensive care and assisted ventilation and by the mortality rate (37 per cent vs. 1.5 per cent, P<0.01). The infection was acquired nosocomially by 21 per cent of infected infants; the mortality rate from nosocomial infection was also higher in infants with congenital heart disease (44 per cent vs. 5 per cent, P<0.01). ...

Mortality Associated with Nosocomial Urinary-Tract Infection

Abstract: In a prospective study, 131 of 1458 patients acquired 136 urinary-tract infections (defined as ≥105 colony-forming units per milliliter) during 1474 indwelling bladder catheterizations. Seventy-six patients (25 infected and 51 noninfected) died during hospitalization; death rates were 19 per cent in infected patients and 4 per cent in noninfected patients. Multiple logistic regression analysis demonstrated that seven of 21 prospectively monitored variables were associated with mortality among the catheterized patients. The adjusted odds ratio for mortality between those who acquired infection and those who did not was 2.8 (95 per cent confidence limits, 1.5 to 5.1). The acquisition of infection was not associated with the severity of underlying disease; among patients who died, infections occurred in 38 per cent of those classified as having nonfatal underlying disease (15 of 39) and in 27 per cent of those classified as having fatal disease (10 of 37). Twelve deaths may have been caused by acqui...

Drug Disposition in Old Age

Abstract: THE appropriate and rational use of drugs by the elderly is a matter of growing medical and social concern. Life expectancy in the Western world currently stands at 69 years for men and 77 years for women and is increasing.1 , 2 In 1980 an estimated 11 per cent of the total population was over 65 years old; the proportion is expected to exceed 15 per cent by the year 2040. As compared with the young, elderly persons on the average spend more money and a greater fraction of their income on health care. Old people have more illnesses and hospitalizations than . . .