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To select topics for quality assurance activities focusing on older patients, we convened a 14-member panel of physicians and experts in quality assurance. In two rounds of ratings, panelists rated 42 medical conditions (eg, pneumonia) in terms of their effects on patient outcomes, the availability of beneficial interventions, and the health benefits from improving current quality. They rated 27 health services (eg, adult day-care) on similar dimensions. The feasibility of doing quality assurance work on each condition and service also was rated. Using the ratings, the conditions selected for quality assurance work were congestive heart failure, hypertension, pneumonia, breast cancer, adverse effects of drugs, incontinence, and depression. Health care services selected were hospital discharge planning, acute inpatient care for the frail elderly, long-term-care facilities (intermediate-care facilities and skilled nursing facilities), home health care services, and case management.
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PMID:Assuring the quality of health care for older persons. An expert panel's priorities. 365

The well-known different morphological features observed in so-called senile cataract are probably symptoms of various pathogenetic mechanisms in the lens. In order to identify a relationship between type of cataract and special risk factors, a cataract classification system using Scheimpflug photography has been developed. Data of 288 cataract patients (case histories and blood chemistries) have been grouped according to differences in cataract morphology. The multivariate analyses showed the following five variables to be important and to contribute independently to the differentiation of cataract types: cholelithiasis, allergy, heart insufficiency, pneumonia, and age. A case-control study without consideration of cataract morphology showed the following variables to be important and to associate independently with the risk of developing cataracts: age, allergy, diabetes, hypotension, hypertension, use of analgesics, and coronary disease.
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PMID:Evaluation of cataract-related risk factors using detailed classification systems and multivariate statistical methods. 369 28

During 1978-1983, 57 maternal deaths (23 in blacks, 32 in coloureds and 2 in whites) occurred among 131,288 deliveries (36,564 in blacks, 89,335 in coloureds and 5389 in whites) in the Peninsula Maternal and Neonatal Service, Cape Town. Data for whites were not analysed further. Maternal mortality rates (MMRs) were higher in blacks than in coloureds. Age- and parity-specific MMRs showed that black teenagers and primiparas and coloureds aged 20-34 years and of parity 2-4 had the lowest rates. Advanced age and grand multiparity had a much greater adverse effect in coloureds than in blacks. Eighteen per cent of deaths in blacks and 9% of those in coloureds were in unbooked patients. The main causes of death (obstetric and non-obstetric) in blacks were sepsis, abruptio placentae, eclampsia and pneumonia. In coloureds they were eclampsia, other manifestations of proteinuric hypertension, cardiac disease, sepsis, haemorrhage (grouped) and diabetes. Of those who died, 43% of blacks and 38% of coloureds had had a caesarean section. The perinatal mortality rate was 417 for blacks and 469 for coloureds. A number of avoidable factors were identified. Most, if not all, deaths occurred because simple perinatal rules were broken.
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PMID:Maternal mortality in Cape Town, 1978-1983. 371 61

Using the formulae of Fazio and coworkers, the regional extravascular lung water per blood volume and flow was calculated in normal volunteers, in patients with left heart failure, sarcoidosis, allergic alveolitis and pneumonia. The double-isotope technique was used. 113mIn-chloride was intravascular tracer and 123I-antipyrine extravascular tracer. They were injected intravenously as rapid bolus. The activity in the lungs was detected with gamma camera and the time-activity curves were generated with PDP-Gamma-11 computer system. Mean transit times were calculated using two different mathematical handlings of the dilution curves, with gamma fitting parameters and by the area-per-height method. The latter method gave mean transit times about double those calculated with gamma fitting parameters, because the peripheral injection decreased the peak height. Therefore, the area per height method to calculate mean transit times by peripheral injection was found to be inaccurate. The control group consisted of 16 healthy adults. In two subjects repeated studies were made in one week. Their individual, regional extravascular lung water values varied somewhat, but were on second examination found to be between the range of the values found from the first examination. The regional extravascular lung water values in patient groups were correlated with corresponding clinical, laboratory and roentgenographic findings. The values for extravascular water discussed on the next page are calculated only by means of transit times with gamma fitting parameters, although the extravascular water values determined by the area-per-height method also significantly increased in patients compared to the control group. The cardiac group consisted of 52 patients, of whom 23 had clinically compensated and 29 decompensated left heart failure. Regional extravascular lung water significantly increased in patients with decompensated heart failure when compared to patients with compensated heart failure. The cardiac group was also divided into three subgroups after radiological grading of pulmonary venous hypertension. Between GR I (n = 17) without signs of venous hypertension and GR II (n = 18) with signs of venous congestion no significant differences in regional extravascular lung water were found. However, in GR I and GR II the values for regional extravascular water increased when compared to the control group, which is probably due to increased perfusion of vessels or increased blood volume in these cardiac patients.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:Measurement of regional extravascular lung water using the double indicator-dilution isotope technique. 391 68

Recently many refugees from Sri Lanka have arrived in Europe. The purpose of the present investigation was to analyze the subjective complaints and diagnoses in these refugees. One hundred refugees (97 males, 3 females, age 19 to 42 years) were investigated. The most common reasons for consulting a general internist were cough (23%), general pain in soft tissue and joints (21%), disorders of the gastrointestinal tract (19%) and ear or throat complaints (15%). In 43% of the patients no diagnosis could be established. 58 patients were investigated for parasites in stool: 57% of these patients had hookworms, 12% non-pathogenic protozoon, 9% Entamoeba histolytica cysts, and 2% Giardia lamblia. In 12% of the patients the diagnosis was tonsillitis or pharyngitis, in 7% bronchitis, pneumonia or asthma and in 5% arterial hypertension. Various other diagnoses were established in 48 patients. With the exception of the high frequency of intestinal parasites, complaints and diagnoses in these refugees were the same as in a comparable European population.
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PMID:[Medical problems in refugees from Sri Lanka (Tamil)]. 396 44

Three patients with rapidly progressive, disseminated malignant pheochromocytoma were treated with a combination chemotherapeutic regimen consisting of cyclophosphamide, vincristine, and dacarbazine in repeated 21- to 28-day cycles. All three patients had a marked decrease in blood pressure and an improvement in performance status within the first few cycles of treatment. At a follow-up of 6 to 13 months all patients continue to receive chemotherapy with further regression of tumor in two and stable disease in one. Their blood pressure is normal with minimal or no antiadrenergic therapy. Therapy has been well tolerated; moderate reversible granulocytopenia, neurotoxicity, and one episode of pneumonitis have been the major toxicities encountered. Thus, combination chemotherapy appears to be effective for symptomatic malignant pheochromocytoma.
Hypertension
PMID:Treatment of malignant pheochromocytoma with combination chemotherapy. 399 32

Ninety patients at the Wilmington Medical Center were enrolled in a comparative study to evaluate the efficacy and toxicity of ticarcillin plus clavulanic acid in the treatment of a variety of infections. Forty-seven women with obstetric or gynecologic infections were randomly assigned to receive ticarcillin plus clavulanic acid or cefoxitin. Forty-three patients with gram-negative septicemia or lower respiratory tract infection were given ticarcillin plus clavulanic acid or tobramycin plus piperacillin in a randomized fashion. Of the 47 women with obstetric or gynecologic infections, 23 were randomly assigned to receive ticarcillin plus clavulanic acid, and 24 were randomly assigned to receive cefoxitin. Several patients in each group had underlying diseases such as diabetes, obesity, and hypertension. Of the 27 pathogens isolated in the group receiving ticarcillin plus clavulanic acid, 26 (96 percent) were eradicated, including all three ticarcillin-resistant pathogens. In the cefoxitin-treated group, 31 of the 33 (94 percent) pathogens were eliminated, including all four ticarcillin-resistant organisms. Three reinfections or superinfections occurred, and cefoxitin therapy failed to eliminate an enterococcus isolate from the endometrium in one patient. The clinical response in both treatment groups was excellent. Either cure or clinical improvement was achieved for all 18 sites of infection in the ticarcillin plus clavulanic acid-treated group and for all 22 sites in the cefoxitin-treated group. There were no systemic drug reactions in either treatment group. In one patient in the cefoxitin-treated group, local phlebitis developed at the infusion site. This reaction responded to local therapy. There were no local reactions among the patients receiving ticarcillin plus clavulanic acid. Of the 43 patients with gram-negative septicemia or lower respiratory tract infection, 21 were randomly assigned to receive ticarcillin plus clavulanic acid and 22 were assigned to receive tobramycin plus piperacillin. Thirty-six patients had gram-negative sepsis, and seven patients had lower respiratory tract infection. Nine of the 36 patients suspected of having gram-negative sepsis were not evaluable because no pathogen was isolated prior to treatment. Twenty-two of the 27 patients treated for septicemia had good clinical and microbiologic responses. Three of the seven patients with pneumonia were not evaluable. Of the four evaluable patients, two had pneumococcus pneumonia; one was treated with tobramycin plus piperacillin and one with ticarcillin plus clavulanic acid. In both instances, the clinical and bacteriologic responses were considered good.
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PMID:Treatment of infections in hospitalized patients with ticarcillin plus clavulanic acid. A comparative study. 407 86

Of 415 adult patients treated for acute drug intoxications in a university hospital emergency room, 64 (15.4%) required admission to the medical service for intensive care. A significantly larger proportion of patients over 40 years of age required hospitalization. Forty-eight of the episodes requiring hospitalization were identified as intentional drug intoxication. Women were admitted in 41 (64.0%) instances while men were admitted on 23 (36.0%) occasions. Non-barbiturate depressants, barbiturates, tranquilizers, and antidepressants were the drug classes most commonly incriminated. Almost one-half of all patients, however, had taken multiple drugs. Medical complications in these 64 patients included coma in 43 (67.2%), acute hypertension or hypotension in 21 (32.8%), and pneumonia in 16 (25%). Complications occurring less frequently were cardiac arrest in three (4.7%), anemia in two (3.2%), neuropathies, soft tissue necrosis, quadraplegia, renal failure, bullous dermatitis, and fetal death in one patient each. Two (3.2%) patients died as a result of drug ingestions. Forty per cent of patients had experienced previous episodes of acute drug intoxication.
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PMID:Epidemiology of acute drug intoxications: patient characteristics, drugs, and medical complications. 444 48

184 cases of acute poststreptococcal glomerulonephritis were investigated and six of these were associated with a peculiar, uncommon pneumonia, and another one had a lethal course. The clinicoradiological and especially pathological data summarized in this study attempt to demonstrate the individuality of this type of pneumonia. Pneumonia associated with acute poststreptococcal glomerulonephritis is similar or identical to rheumatic pneumonia. In both entities, pneumonia and pulmonary edema may and do coexist, and the differentiation of pneumonia from congestive heart failure is difficult and often impossible without pathological evidence. The most attractive pathogenic interpretation is the hypothesis of an immune mechanism in the induction of pneumonia. Authors attributed the lung changes, consecutive to a vascular damage, to a hypersensitivity phenomenon, with accumulation of fibrinogen in alveoli where it is converted to fibrin. Then, the hyaline membrane lining the alveoli, an important feature of pneumonia associated with glomerulonephritis is built up. It is, however, plausible that the effect of the immune reaction is associated with those of hydrosaline retention, arterial hypertension and congestive heart failure. Analogous to rheumatic pneumonia, the "peculiar pneumonia" associated with acute poststreptococcal glomerulonephritis should be named nephritic pneumonia.
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PMID:Uncommon pneumonia associated with acute poststreptococcal glomerulonephritis. 621 50

During the past five years 75 patients aged 90 years or more had 85 major surgical procedures at the Metropolitan Nashville General and Vanderbilt University hospitals. The most common operation was exploratory laparotomy. The second was lower extremity amputation for peripheral vascular disease and/or gangrene. Fifty-seven percent had general endotracheal anesthesia. Associated medical problems were common, and included congestive heart failure (24%), hypertension (21%), diabetes mellitus (13%), chronic arrhythmias (9%), history of myocardial infarction (8%), and history of cerebrovascular accident (5%). Eleven patients (13.4%), six of whom had general anesthesia, died after operation. Of these, two had postoperative pneumonia, two did not recover from bowel perforation and peritonitis, one had a postoperative myocardial infarction, another had a cerebrovascular accident, and one had sepsis. One patient's sudden death was likely due to myocardial infarction or pulmonary embolus. The other three deaths occurred in patients with extensive carcinomas (gallbladder carcinoma in one and widely metastatic carcinoma of unknown origin in two). These three patients died of the disease for which they were operated upon when the operation failed to alter its course. When surgical procedures are necessary to prolong and/or improve the quality of life in elderly patients, these procedures may be done in most cases with acceptable results.
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PMID:Surgical procedures in patients aged 90 years and older. 649 54


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