Biomedical subjects
Publications and source records attributed to M R Kramer.
An unusual case of temporal arteritis presenting with sensorineural hearing loss is presented. Deafness was improved dramatically by corticosteroid treatment. The diagnosis of temporal arteritis should be considered in elderly patients presenting with sensorineural hearing loss.
To determine the factors affecting outcome of acute renal failure (ARF) in the elderly, we retrospectively studied 44 patients over the age of 65 who had undergone acute peritoneal dialysis. Thirteen patients (29%) survived 2 months or longer after dialysis treatment ("survivors"). Thirty-one patients (71%) died within this period ("nonsurvivors"). The main factor distinguishing survivors was the frequency of sepsis (none of 13 survivors vs 17 of 31 nonsurvivors). Preexisting malignancy and total number of acute insults to renal function were significantly less frequent, and immediate clinical and biochemical outcome of dialysis significantly better in survivors. The overall complication rate of dialysis was high (31 of 44 patients), but was significantly lower in survivors. Acute peritoneal dialysis is a useful procedure in the management of ARF in the elderly. However, we suggest that elderly patients in whom sepsis is a contributory factor to the development of ARF do not benefit from peritoneal dialysis therapy.
During the years 1974 to 1986, 44 young soldiers (mean age 21 +/- 3 years) died suddenly and unexpectedly in the Israel Defense Forces. Cardiac causes accounted for 54 percent of deaths; neurologic causes, 14 percent of deaths; other diseases, 9 percent; and in 23 percent, cause of death was unknown. Although most sudden deaths are considered unpredictable, preceding symptoms were reported in more than one half of the patients. We found that syncope had occurred in 23 percent of cases, chest pain in 11 percent, and febrile disease in 16 percent. Exercise-associated syncope occurred in 16 percent and exercise-associated death occurred in most (86 percent) of those cases. Diagnosis at the time of the preceding symptoms failed to predict the fatal diseases in most cases. Our report points out the high incidence of syncope prior death in young soldiers with sudden death. Although further prospective controlled studies are needed in order to confirm that impression, we suggest that the possibility of syncope followed by sudden death should be kept in mind while evaluating young patients presenting with exercise-associated syncope.
Temporal arteritis is a well-recognized multi-systemic disease. Pulmonary manifestations, however, are extremely rare. In two patients with biopsy-proven temporal arteritis, lung involvement was observed. One patient presented with multinodular pulmonary lesions, while the second had a diffuse interstitial pattern. Both patients responded well to corticosteroid treatment. In a review of the literature, only four additional cases associating lung involvement with temporal arteritis were found. The possibility of primary pulmonary vasculitis should be considered in elderly patients with temporal arteritis.
We evaluated 104 cases of pneumococcal bacteremia retrospectively: 55 adults and 49 children. The overall mortality rate was 33% in adults, and 6% in children. Mortality was associated with old age, severe underlying disease, vague clinical presentation, multilobar pneumonia, leukopenia and metabolic acidosis. Both vigorous treatment with mechanical ventilation devices, vasopressors and steroids, and sophisticated monitoring in the Intensive Care Unit did not improve survival. In six cases (5.8%) the pneumococcus was resistant to penicillin G. In reviewing the literature of the last 30 years, no change in mortality rate was noted. Vaccination of population at risk is highly recommended.
The prevalence of complement deficiency was studied among 111 survivors of sporadic meningococcal disease located through the medical records of 10 Israeli hospitals. There were 11 patients with CH50 = 0: one with systemic lupus erythematosus and 10 with hereditary terminal complement deficiency (four with homozygous C7 and six with C8 deficiency). There was no hereditary complement deficiency among 39 Ashkenazi subjects as against 18 per cent among 38 Sephardi subjects and 40 per cent among 15 of Moroccan ancestry (p less than 0.05). The age at first presentation of meningococcal disease in complement deficient patients was 14.7 +/- 7.6, years compared with 8.1 +/- 10.9 in the non-deficient patients (p less than 0.025). None of the complement deficient patients had meningitis below the age of 5 years vs. 49 per cent of non-deficient subjects. Recurrent meningitis was observed in 40 vs. 4 per cent (p less than 0.01) and meningitis in siblings in 40 vs. 2 per cent respectively (p less than 0.001). In addition to the 10 propositi, 11 non-propositus siblings were identified with severe complement deficiency (six with homozygous C7 and five with C8 deficiency). Seven of the non-propositi had no history at all of meningitis or any other serious systemic disease, underlining the relatively favourable prognosis of terminal complement deficiency. With increasing familiarity with the clinical features of this hereditary disease, it is possible now to identify on clinical grounds patients with meningococcal disease with a high likelihood of terminal complement deficiency.
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Severe immune haemolytic anaemia and thrombocytopenia developed in a 71-year-old female within 10 d of starting diclofenac (Voltarol) therapy. These complications resolved within 3 weeks of discontinuation of the drug and corticosteroid therapy. A warm autoantibody of the IgG type together with C3 was found in the direct antiglobulin test of the patient's RBC. The patient's serum and RBC eluate contained a warm autoantibody which reacted with all commercial panel cells without the addition of diclofenac, and gave a negative reaction with Rh null and -D- RBC. This pattern of interactions is similar to haemolysis associated with alpha-methyldopa, indicating the presence of autoantibodies directed against structural components common to all Rh antigens. The coexistence of immune thrombocytopenia and immune haemolytic anaemia is suggestive of an autoimmune disease caused by modified T-cell regulation. Although immune haemolytic anaemia is a rare complication of diclofenac therapy, our observations illustrate the severity of haemolytic anaemia in the occasional patient and stress the need for increased awareness of such a development.
We describe a patient with primary amyloidosis in whom multiple osteolytic lesions caused by amyloid bone tumours developed, and review the clinical features of the 18 cases with primary amyloidosis in whom destructive bone lesions have been reported. In contrast to amyloidosis associated with multiple myeloma, destructive lesions in the primary disease are mainly located to long bones; joint involvement is common, and radionuclide bone scan shows pronounced uptake of 99mTc-PP by the destructive bone lesions. Despite the superficial similarity between the destructive bone lesions associated with primary amyloidosis and multiple myeloma, distinction between these entities on clinical grounds is possible and may be easily confirmed by direct aspiration of the osteolytic infiltrates.
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A 55 year old woman in thyrotoxic crisis developed atrial fibrillation, atrioventricular block, and sinoatrial block in rapid succession. All of these abnormalities resolved completely after antithyroid treatment. This course of events illustrates the profound effect of thyroid hormones on cardiac function. In view of the potential aggravation of atrioventricular conduction disturbance by beta adrenergic blocking agents, thyrotoxic patients should be carefully screened for electrocardiographic evidence of conduction disturbance before the administration of such drugs.
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Recent upsurge in the use of physiologic data for medical diagnostic and treatment procedures has prompted the medical profession to use the computer to automate and reduce the time required for data processing. Although the digital computer has traditionally been used to perform these tasks, a hybrid computer (combined analog and digital) has been found to provide many advantages over the digital computer, especially where on-line data processing is concerned. As a result, the Bio-Medical Engineering Center has installed a centrally located hybrid computer system at Ohio State University. One of the applications of this system has been processing cardiac catheterization data. Data is transmitted between the hospital and computer via infrared optics. The data can be analyzed in real time, with the results immediately available to the physician.
During the past two decades, the number of charitable foundations in the United States has doubled while the value of their assets has increased more than 1,100%. As new wealth continues to pour into foundations, the authors take a timely look at the field and conclude that radical change is needed. First, they explain why. Compared with direct giving, foundations are strongly favored through tax preferences whose value increases in rising stock markets. As a nation, then, we make a substantial investment in foundation philanthropy that goes well beyond the original gifts of private donors. We should therefore expect foundations to achieve a social impact disproportionate to their spending. If foundations serve merely as passive conduits for giving, then they not only fall far short of their potential but also fail to meet an important societal obligation. Drawing on Porter's work on competition and strategy, the authors then present a framework for thinking systematically about how foundations create value and how the various approaches to value creation can be deployed within the context of an overarching strategy. Although many foundations talk about "strategic" giving, much current practice is at odds with strategy. Among the common problems, foundations scatter their funding too broadly, they overlook the value-creating potential of longer and closer working relationships with grantees, and they pay insufficient attention to the ultimate results of the work they fund. This article lays out a blueprint for change, challenging foundation leaders to spearhead the evolution of philanthropy from private acts of conscience into a professional field.
Hyperbilirubinemia is commonly observed in long-standing pulmonary hypertension and is thought to be the result of chronic right ventricular failure and subsequent liver congestion. To evaluate the clinical significance of preoperative hyperbilirubinemia, we reviewed the cases of 62 patients with pulmonary hypertension (31 primary and 31 Eisenmenger's syndrome) who underwent heart-lung transplantation between 1981 and 1990 at Stanford. Bilirubin levels higher than 1.0 mg/dl were noted in 58% of patients, and bilirubin levels higher than 2.0 mg/dl were noted in 23% of patients. Indirect hyperbilirubinemia accounted for 66% to 87% of the total bilirubin and tended to fluctuate with diuretic therapy. It was associated with polycythemia, reticulocytosis, and mild elevations of liver enzymes. Early postoperative mortality in patients with total bilirubin levels greater than 2.1 mg/dl, bilirubin levels greater than 1 mg/dl but less than 2.0 mg/dl, and levels less than 1 mg/dl was 58%, 27%, and 16%, respectively (p less than 0.05). In those with high bilirubin levels, four patients had severe hemorrhage as part of their terminal event. Cardiac cirrhosis was found at autopsy in 75% of the early deaths of patients with high bilirubin. We conclude that hyperbilirubinemia is a late manifestation of pulmonary hypertension. The mechanism of hyperbilirubinemia is probably the result of the combination of increased hemolysis and decreased uptake by the chronically congested liver. Patients with pulmonary hypertension and hyperbilirubinemia appear to be at greater surgical risk during heart-lung transplantation.
Obliterative bronchiolitis is the most significant long-term complication of lung and heart-lung transplantation characterized by the rapid development of obstructive airway disease. It is thought to be a manifestation of chronic rejection and has been treated, with limited success, with augmentation of immunosuppression. Early detection of obliterative bronchiolitis and prompt initiation of therapy may result in an improved outcome. The role of transbronchial biopsy has been reported in the diagnosis of acute rejection and infection but not for obliterative bronchiolitis. To study this problem we retrospectively reviewed the transbronchial biopsy results of patients with advanced clinical obliterative bronchiolitis, as defined physiologically. Between January 1, 1988, and December 31, 1991, 46 "sets" of adequate transbronchial biopsy specimens were obtained from 16 patients (15 heart-lung recipients and one double lung recipient). Seven sets of transbronchial biopsy specimens (15.2%) showed obliterative bronchiolitis by pathologic study. In four patients with severe clinical obliterative bronchiolitis, only one transbronchial biopsy specimen of seven (14.3%) showed obliterative bronchiolitis. The pathologic diagnosis of obliterative bronchiolitis was confirmed in three of these patients at the time of autopsy or retransplantation. Twelve patients were still alive at the end of the study period, and all experienced further deterioration of lung function typical for obliterative bronchiolitis. We conclude that the sensitivity of transbronchial biopsy for obliterative bronchiolitis is poor. Possible explanations for these results are explored.