Beyond the living will

Sixty-three residents of a retirement community with living wills were studied to see if more specific planning for, and thus control over, their dying process would decrease their anxiety about death. The experimental group received intervention in the form of counseling and filling out a questionnaire regarding specific treatments (e.g., CPR, feeding tubes), proxy decision making, and other related questions. Results show that the mean death anxiety score for the experimental group decreased, whereas the control group's mean score did not change significantly.

Technology and outpatient review: a preliminary evaluation

Most health care utilization and cost control programs focus on inpatient care or on high-cost, catastrophic illnesses or injuries. Recently, however, Parkside Health Management Corporation has developed a utilization review program that targets treatments and high-technology procedures performed primarily in an outpatient setting, as well as specific inpatient procedures not included in other review programs. These include chiropractic, podiatric, and physical therapy treatments; cesarean section; and endoscopy, ultrasound in pregnancy, and lithotripsy. The treatments/procedures examined in this program, called Technology and Outpatient Review (TOR), account for approximately 6% of claims expenses. Bigel Institute for Health Policy researchers are evaluating a pilot test to determine TOR's effect on health care costs and utilization, appropriateness, and patient satisfaction.

Changes in food patterns during a low-fat dietary intervention in women

The Women's Health Trial was initiated by the National Cancer Institute to study the effects of a low-fat diet on the incidence of breast cancer in women at elevated risk for the disease. The purpose of this article is to examine the specific dietary changes that 173 women made while participating in a feasibility intervention program to reduce their fat intake to approximately 20% of total calories over a 12-month period. The intervention program used group sessions to teach nutrition information and behavioral skills necessary to make a life-style dietary change. Four-day food records were collected from participants at the beginning of the study and again at 12 months. Women in the intervention group reduced their total fat intake from a mean of 76 gm (39% of total energy) to 31 gm (22% of total energy), mainly by decreasing their fat intake from milk products, red meats, and fats/oils. These women used cheddar cheese, American cheese, whole milk, butter, mayonnaise, salad dressing, bacon, and hamburgers less frequently, and used diet American cheese, low-fat cottage cheese, and skim milk more frequently. They consumed less fat in their vegetable dishes, and their total caloric intake from fruit increased slightly. In addition, the overall quality of the diets improved, since there was a 20% to 50% increase in the energy-adjusted intake of vitamins and minerals from food sources.

Analysis of the costs of a large prevention trial

Total direct costs of the Women's Health Trial (WHT), a large multicenter prevention trial, were reduced by more than 50% by means of research cost analysis conducted during the trial design phase. The unit costs of specific trial activities were estimated so that total direct costs of the trial could be predicted from design parameters. The relative costs of screening, treatment, and follow-up, and the fixed costs associated with each clinical center in a multicenter prevention trial were taken into account. Direct costs of the WHT were reduced from +195 million to +95 million by refinement of the trial protocol, selection of an efficient design, and consideration of trial logistics. The analyses suggest several ways to reduce costs in a prevention trial. Use of the case-cohort approach can reduce costs substantially when the protocol includes collection of specimens or data that are costly to process. When establishing and maintaining a clinical center represents a significant proportion of a clinical center's costs, use of a smaller number of larger clinical centers offers important cost savings. Because restrictive eligibility requirements reduce the recruitment potential of each clinical center, use of high-risk participants may not improve the efficiency of a prevention trial; its favorable impact on sample size may fail to compensate for its cost in terms of additional clinical centers and higher recruitment costs.

Some determinants of attrition in prospective studies on aging

Demographic measures, psychosocial variables, and objective and subjective measures of physical impairment were assessed in elderly men twice at intervals of 12 to 18 months. Canonical discriminant function analysis of the relationship between these predictor variables on the first testing and whether participants (a) returned for retesting, (b) did not return because of apparent disinterest, or (c) did not return because of illness or death, revealed two significant canonical variates. The first, characterized by decreased mental and physical capacity, discriminated between the deceased/ill group and the other two groups. The second was characterized by decreased social interaction and life satisfaction, and increased life events, and distinguished between the disinterested group and the other two groups. However, both groups that failed to return for retesting showed evidence of impaired physical health and a general disengagement from social and personal activities, compared to the retested group.

Two approaches to measuring quality in medical case management programs

In a study of the quality of care in a medical case management program, five physician experts, applying criteria to medical records, found the care provided appropriate in a majority of 40 cases (10 each of head injury, spinal cord injury, high-risk infants, and AIDS). Nurses interviewing parents of 30 high-risk infants found general satisfaction with case management.

Major increases in spermidine/spermine-N1-acetyltransferase activity by spermine analogues and their relationship to polyamine depletion and growth inhibition in L1210 cells

As an antiproliferative strategy, we are using bis(ethyl) derivatives of spermine to suppress polyamine biosynthetic enzyme activity and, thereby, deplete intracellular polyamine pools. Since certain of these analogues have recently been shown to potently increase spermidine/spermine-N1-acetyltransferase activity, we have investigated the relationship of this effect to growth inhibition and polyamine depletion. The cellular effects of N1,N12-bis(ethyl)spermine (BESPM) and two of its homologues, N1,N11-bis(ethyl)norspermine (BENSPM) and N1,N14-bis(ethyl)homospermine (BEHSPM), were compared in L1210 cells following treatments at equimolar concentrations (2 microM) and at concentrations (0.5 microM BEHSPM; 2 microM BESPM, and 20 microM BENSPM) producing comparable intracellular concentrations (2600-3000 pmol/10(6) cells) of the analogues. At 2 microM, BENSPM increased total polyamine N-acetyltransferase activity by 15-fold, BESPM, by 7-fold, and BEHSPM, by only 1.5-fold. These differences were much more exaggerated at comparable intracellular concentrations, where BENSPM increased enzyme activity 31-fold, BESPM, 7-fold, and BEHSPM had no effect. This rank order in effectiveness sharply contrasted effects on cell growth and interference with polyamine biosynthesis, which correlated more with intracellular accumulation of the analogues. At 2 microM, BEHSPM was most effective in suppressing ornithine and S-adenosylmethionine decarboxylases, depleting polyamine pools, and inhibiting cell growth, followed by BESPM and then by BENSPM. Thus, the data indicate that, in L1210 cells, the large increases in spermidine/spermine-N1-acetyltransferase activity produced by the analogues do not appear to contribute significantly to polyamine depletion or to be causally related to inhibition of cell growth. These studies also identify BENSPM as the most potent modulator of spermidine/spermine-N1-acetyltransferase activity thus far studied in cell culture systems. To a large extent, its greater effectiveness over BESPM seems to be attributable to a major increase in prolongation of enzyme half-life (3.9 versus 1.3 h), presumably due to enzyme stabilization caused by differential binding of the analogues at the enzyme active site.

Mutations in nuclear gene cyt-4 of Neurospora crassa result in pleiotropic defects in processing and splicing of mitochondrial RNAs

The nuclear cyt-4 mutants of Neurospora crassa have been shown previously to be defective in splicing the group I intron in the mitochondrial large rRNA gene and in 3' end synthesis of the mitochondrial large rRNA. Here, Northern hybridization experiments show that the cyt-4-1 mutant has alterations in a number of mitochondrial RNA processing pathways, including those for cob, coI, coII and ATPase 6 mRNAs, as well as mitochondrial tRNAs. Defects in these pathways include inhibition of 5' and 3' end processing, accumulation of aberrant RNA species, and inhibition of splicing of both group I introns in the cob gene. The various defects in mitochondrial RNA synthesis in the cyt-4-1 mutant cannot be accounted for by deficiency of mitochondrial protein synthesis or energy metabolism, and they suggest that the cyt-4-1 mutant is defective in a component or components required for processing and/or turnover of a number of different mitochondrial RNAs. Defective splicing of the mitochondrial large rRNA intron in the cyt-4-1 mutant may be a secondary effect of failure to synthesize pre-rRNAs having the correct 3' end. However, a similar explanation cannot be invoked to account for defective splicing of the cob pre-mRNA introns, and the cyt-4-1 mutation may directly affect splicing of these introns.

Plasma amino acid concentrations in parenterally fed preterm infants

One hundred and nine sick preterm infants were studied, and the data obtained show that hyperphenylalaninaemia is an extremely rare occurrence as long as an adequate source of energy is provided. High concentrations of the other aromatic amino acid (tyrosine) on the other hand, were often encountered and seem to be due to immaturity of an isolated hepatic enzyme as there was no correlation between phenylalanine and tyrosine concentrations. Possible adverse consequences of hypertyrosinaemia are discussed in relation to toxicity and the assessment of hepatic function. We provide reference centiles for plasma amino acid concentrations in this population.

Causal relation between the pressure gradient and left ventricular ejection time in hypertrophic cardiomyopathy

This study was designed to evaluate the relation between severity of obstruction to left ventricular outflow and left ventricular ejection time in hypertrophic obstructive cardiomyopathy. With dual catheters across the left ventricular outflow tract, the pressure gradient and corresponding left ventricular ejection time were measured in 10 patients as the pressure gradient was pharmacologically provoked or abolished, or both. The patients were studied during constant atrial pacing to avoid the potential errors introduced with heart rate correction equations. The pressure gradient was pharmacologically provoked or reduced over a range of greater than or equal to 62 mm Hg per patient. In each patient the left ventricular ejection time varied directly with the pressure gradient (mean r = 0.97, range 0.92 to 1.00). The change in magnitude of the pressure gradient varied directly with the corresponding change in the measured ejection time (mean r = 0.98, range 0.97 to 1.00). When the data from all 10 patients were pooled with use of Weissler's heart rate correction equation, the relation between the corrected left ventricular ejection time and the pressure gradient was still significant and linear (r = 0.86), but less so than in individual patients. This difference was the result of marked interpatient variability in the slope of this linear relation reflecting interpatient differences in other important factors, such as underlying myocardial contractility and stroke volume, that influence left ventricular ejection time. This study demonstrates a clear, direct and highly significant relation between the magnitude of the pressure gradient and the left ventricular ejection time in hypertrophic obstructive cardiomyopathy.(ABSTRACT TRUNCATED AT 250 WORDS)

Unilateral facial actinic elastotic plaque--a new clinical variant of actinic elastosis

The case is reported of an 82-year old woman with a four month history of an erythematous indurated plaque on the left cheek. Light and electron microscopy demonstrated the presence of solar elastosis alone. We believe that this is a new clinical variant of solar elastosis. The spectrum of cutaneous actinic damage is reviewed.

Disopyramide in hypertrophic cardiomyopathy. I. Hemodynamic assessment after intravenous administration

The hemodynamic effects of intravenous disopyramide were determined in 43 patients with hypertrophic cardiomyopathy and pressure gradients at rest (resting obstruction). The basal subaortic pressure gradient decreased in all patients by a mean of 61 mm Hg (range 16 to 123); in 35 patients the gradient was abolished (less than 20 mm Hg). The reduction in pressure gradient was achieved through a decrease in left ventricular systolic pressure, from 178 to 135 mm Hg (p less than 0.0001), and a rise in aortic systolic pressure, from 105 to 123 mm Hg (p less than 0.0001). Left ventricular ejection time was reduced from 326 to 273 ms (p less than 0.0001). Left ventricular end-diastolic pressure decreased from 19 to 16 mm Hg (p less than 0.0001). In a subgroup of 13 patients, cardiac output was unchanged after disopyramide, despite a prolongation of the pre-ejection period from 104 to 137 ms (p less than 0.0001) indicating a decrease in contractility. The maintenance of cardiac output, despite a decrease in contractility, may reflect a decrease in mitral regurgitation resulting from the reduction of systolic anterior motion of the mitral valve by disopyramide. These results indicate that disopyramide produces predictably favorable hemodynamic effects in patients with hypertrophic cardiomyopathy and resting obstruction to left ventricular outflow.

Haematological, neurological and psychiatric complications of chronic hypothermia following surgery for craniopharyngioma

A patient is described who became poikilothermic following surgery for removal of a craniopharyngioma. Episodes of disturbed behaviour, neurological abnormalities, pancytopenia and deranged liver function could be correlated with episodes of more profound hypothermia on a background of a chronically lowered core temperature. The association of pancytopenia and neuropsychiatric disturbances with hypothermia is discussed with reference to reported cases of periodic spontaneous hypothermia.

The effects of two calcium antagonists (nifedipine and verapamil) on renal function in sheep

The effects of the calcium antagonists, nifedipine and verapamil, were measured in five conscious Merino ewes at a dose rate of 0.5 microgram min-1 kg-1 for 60 min. Nifedipine caused a significant fall in mean arterial blood pressure (MABP) and central venous pressure (CVP) and an increase in heart rate (HR). There was no significant effect on renal vascular resistance (RVR) but, with the fall in MABP, renal plasma flow (RPF) decreased. There was a significant rise in glomerular filtration rate (GFR) and a small rise in filtration fraction (FF). Solute excretion, urine osmolality and solute-free water reabsorption (Tc, H2O) increased and urine flow (V) decreased. Plasma potassium (PK) and osmolality (Posm) decreased. Verapamil produced a similar fall in MABP and also had similar effects on the other parameters, except that in this case RVR was significantly reduced and there were significant increases in RPF and GFR. The rise in GFR which occurred regardless of the change in RPF, can account for the increase in solute excretion, although an effect of the calcium antagonists on tubular function cannot be excluded.

Aspirin and dipyridamole in the prevention of restenosis after percutaneous transluminal coronary angioplasty

To examine the role of antiplatelet therapy in the prevention of arterial restenosis after percutaneous transluminal coronary angioplasty (PTCA), we conducted a randomized, double-blind, placebo-controlled study in 376 patients. The active treatment consisted of an oral aspirin-dipyridamole combination (330 mg-75 mg) given three times daily, beginning 24 hours before PTCA. Eight hours before PTCA, the oral dipyridamole was replaced with intravenous dipyridamole at a dosage of 10 mg per hour for 24 hours, and oral aspirin was continued. Sixteen hours after PTCA, the initial combination was reinstituted. Treatment was continued in patients with a successfully dilated vessel until follow-up angiography four to seven months after PTCA--or earlier, if symptoms dictated. Of 249 patients who underwent follow-up angiography, 37.7 percent of patients receiving the active drug had restenosis in at least one segment, as compared with 38.6 percent of patients taking placebo (P not significant). The number of stenotic segments was virtually the same in the two groups. Among the 376 randomized patients, there were 16 periprocedural Q-wave myocardial infarctions--13 in the placebo group and 3 in the active-drug group (6.9 percent vs. 1.6 percent, P = 0.0113). Although the use of this antiplatelet regimen before and after PTCA did not reduce the six-month rate of restenosis after successful coronary angioplasty, it markedly reduced the incidence of transmural myocardial infarction during or soon after PTCA. Thus, the short-term use of antiplatelet agents in relation to PTCA can be recommended.

Statistical design of the Women's Health Trial

The National Cancer Institute has initiated a randomized trial to determine whether a low fat diet can reduce the incidence of breast cancer among women at increased risk for this disease. A feasibility trial involving 303 women has been conducted to examine recruitment strategies, study short-term compliance and, more generally, develop and refine trial procedures. The feasibility trial group also developed a detailed full-scale trial design plan, and randomization of participants to such a trial is currently underway. The purpose of this report is to describe the major design features of this Women's Health Trial, with particular emphasis on the statistical aspects of the design. The trial is planned to last 10 years and to include 32,000 participants. Of these 32,000 women, 12,800 will be assigned to a low fat diet intervention, and the other 19,200 will constitute a control group. The sample size of 32,000 arises from a range of estimates and assumptions pertaining to (a) the incidence of breast cancer at enrollment corresponding to selected eligibility criteria, (b) the relative risk of breast cancer as a function of a woman's history of dietary fat intake, (c) compliance assumptions in terms of average percent fat in the intervention and control groups as a function of time from randomization, and (d) rates of competing causes of death. These estimates and assumptions will be discussed, as will the robustness of the intended sample sizes to departures from such design assumptions.

Executive functions in unipolar depression before and after electroconvulsive therapy

A neuropsychological investigation of executive functions in patients with unipolar depression was conducted. Ten patients with unipolar depression were tested before, 48 hours after, and 3 months after ECT. Control subjects were tested at similar intervals. Measures included 10 executive and related tasks (20 variables) on which frontal lobe lesion patients have been previously shown to be differentially impaired, and 1 "nonexecutive" task. Patients were significantly inferior to controls on 9 of the executive and related variables before treatment and performed slightly worse 48 hours after treatment. Significant improvement after 3 months was absent. Depressed patients were not impaired on the "nonexecutive" task.

Symptomatic HIV infection of the CNS in a patient without clinical evidence of immune deficiency

Major depression with psychotic features, dementia, and focal neurologic abnormalities appeared in a Haitian man without AIDS or other syndromes of immune compromise. Neurologic evaluation, including brain biopsy, was nondiagnostic, but CSF culture revealed human immunodeficiency virus (HIV).

Complications associated with the guide wire in percutaneous transluminal coronary angioplasty

This report describes three cases of unraveling of the platinum coil of the guide wire during percutaneous transluminal coronary angioplasty. In one case the wire ruptured and required surgical removal. The exact cause of this phenomenon is not known, but wire entrapment may be a factor. This is more likely to occur with tortuous vessels. Precautions to avoid uncoiling and rupture of guide wires during coronary angioplasty are discussed.

Carbamazepine, diuretics, and hyponatremia: a possible interaction

Although carbamazepine is known to cause hyponatremia, no previous reports have indicated an interaction between carbamazepine and a diuretic. Two patients are described who were treated with this combination and developed symptomatic hyponatremia, which cleared when both drugs were discontinued in one patient and when the diuretic was discontinued in the second patient. The possible mechanisms of action of carbamazepine-induced hyponatremia are discussed.