Biomedical subjects
R G Douglas
Publications and source records attributed to R G Douglas.
Metabolic response to sepsis and trauma.
This review examines current knowledge regarding the metabolic responses to trauma and sepsis. The factors which may mediate the responses are discussed and the potential value of pharmacological or nutritional manipulation is reviewed.
Relation of chronic disease and immune response to influenza vaccine in the elderly.
The ability of elderly patients to mount an adequate immune response to influenza vaccine has been debated. We studied the serum haemagglutination inhibition (HI) antibody response in elderly persons to determine whether different degrees of chronic illness were a critical factor in immune response. In autumn 1986, trivalent split virus vaccine was used to immunize 87 healthy ambulatory elderly adults and 53 institutionalized elderly adults. The pre-vaccination health status of the healthy elderly group was significantly better as measured by the incidence of chronic disorders and drug use (p less than 0.02) and by the Chronic Health Evaluation component of the APACHE severity of disease classification (p less than 0.001). No group differences were observed in serum HI antibody after immunization with the trivalent influenza vaccine. However, in 28 patients from each group who received the monovalent A/Taiwan/86(H1N1) vaccine 1 month after the trivalent vaccine, the percentage with a postvaccination HI titre greater than or equal to 40 was 57% (16 of 28) for the healthy elderly vs 7% (2 of 28) for the institutionalized elderly (p = less than 0.001). Geometric mean postvaccination HI titres were 31 and 13, respectively (p = 0.004). We concluded that the institutionalized elderly in our study mounted an inferior immune response against the new heterotypic influenza A/Taiwan strain when compared to healthy elderly adults. The Chronic Health Evaluation score may be an effective predictor of a poor immune response to new influenza vaccine strains in the elderly. Increasing age per se and lack of a history of prior influenza immunization did not adversely affect the development of protective levels of serum antibody.(ABSTRACT TRUNCATED AT 250 WORDS)
Primary gastric lymphoma in Auckland, New Zealand.
The case-notes of 30 patients presenting with primary gastric lymphoma in the Auckland area during 1969-87 have been reviewed. The mean age of the study group was 62 years, and 16 were female and 14 were male. There were 22 European, one Maori and seven Polynesian patients. The most common presenting symptom was abdominal pain and five patients presented acutely with gastrointestinal haemorrhage. The lesions occurred more frequently in the distal stomach and half were polypoid and half were ulcerating. They tended to be of substantial size at presentation, with seven being greater than 10 cm in diameter. Nine lesions were confined to the stomach, 12 involved the surrounding lymph nodes and eight were invading adjacent organs. Twenty-three patients underwent partial or total gastrectomy. Four of these received postoperative radiotherapy, and adjuvant chemotherapy was administered to 13. Chemotherapy, or combination chemo- and radiotherapy were used as the primary treatment in seven patients. Following surgical treatment, 18 patients remained alive and well. Five of the seven patients treated nonsurgically were dead of disease at the time of study and the other two remained alive with persisting disease. The following factors were found to affect prognosis adversely: weight loss of greater than 5 kg, tumour invasion of adjacent organs, and non-surgical primary treatment. Involvement of the lymph nodes draining the stomach did not appear to worsen the outlook, and there was little correlation between lesion size and prognosis.
Analysis of virus and host factors in a study of A/Peking/2/79 (H3N2) cold-adapted vaccine recombinant in which vaccine-associated illness occurred in normal volunteers.
Live attenuated cold-adapted influenza vaccine is undergoing evaluation in man. Several strains have proven to be safe, immunogenic, nontransmissible, and protective against experimental challenge. In this study of A/Peking/2/79(H3N2), with six internal genes from the cold-adapted (Ca) parent A/Ann Arbor/6/60(H2N2), we encountered at the highest input multiplicity, 28% illness rate among individuals infected with vaccine. Reversion to wild type and excessive viral replication did not occur. Physical characteristics of the vaccine were similar to nonreactogenic vaccine A/Washington/897/80(H3N2). At ten- and 100-fold lower input multiplicities, infection frequency was maintained, but reactions did not occur. We compared the observations in this study with those made in a similar study of A/Scotland/840/74(H3N2), a cold-adapted vaccine with five genes from the Ca parent in which reactogenicity also was noted. The dose of vaccine virus in relation to tissue culture infectious doses required to infect 50% of susceptibles (HID50) was proportionally lower for both A/Peking/2/79(H3N2) and A/Scotland/80(H3N2). Hence, when the vaccine was undiluted the recipients were inoculated with more than 100 HID50. We concluded that the very high input could be avoided if vaccines were screened beginning at 1/1,000 of maximum titers. Ca vaccines must be safe before they undergo field trials.
Clinical assessments as predictors of one year survival after hospitalization: implications for prognostic stratification.
In clinical trials measuring the short term survival of patients, prognostic stratification is important to avoid susceptibility bias. Demographic and disease specific clinical features are commonly used to established similarity, but these may not insure prognostic comparability. To identify the generic predictors of one year survival after hospitalization, a cohort of 559 patients admitted to the medical service at New York Hospital was studied. Among all of the clinical and demographic information available at the time of admission, only three were independent predictors of the time until death: functional ability, severity of illness and extent of comorbid disease. The overall one year survival rate was 66%. Six subgroups composed of patients with different combinations of the predictors of prognosis had mortality rates ranging from 97% to 14%. Illness severity was a predictor only in the less functional patients, and only severe comorbidity was associated with a decreased survival after taking into account functional ability and illness severity. Prospective estimates of severity of illness, functional ability and extent of comorbidity can be used to stratify a diverse group of patients according to their probability of one year survival after hospitalization.
Influenza prevention and treatment. The primary care physician's role.
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Hepatic trauma in Auckland.
A retrospective review of 102 cases of hepatic trauma in the Auckland area between 1979 and 1985 is presented. Particular attention has been focused on those cases where there was massive bleeding, and the prognostic factors that govern outcome have been determined. Mechanism and multiplicity of injury, and the presence of severe hypotension (systolic blood pressure less than .80 mmHg) either at presentation or following induction of anaesthesia were the four most important determinants of prognosis. Blunt trauma caused 82% of these cases, with the mortality in this group being 27%, compared with 6% for penetrating trauma cases. The mortality of those patients who presented with a systolic blood pressure less than 80 mmHg was 44% compared with 13% for those whose blood pressure was above 80 mmHg. Thirteen patients sustained severe bursting or avulsion-type injuries, in eight of whom extensive resection of formal lobectomy was performed with a survival of 88%. The remainder exsanguinated either pre-operatively (two patients) or before definitive hepatic surgery was begun (three patients). All patients with caval or retrohepatic venous injuries exsanguinated either pre- or intra-operatively. It is concluded that the mortality of liver injury from blunt trauma far exceeds that of penetrating trauma, and that severe hypotension at the time of presentation indicates a poor prognosis. A good outcome is possible in those patients who have a significant disruption of the liver architecture of one lobe following resection of devitalized tissue. Caval or retrohepatic venous-type injuries carry a grave prognosis.
Melanoma of the head and neck in Auckland.
A series of 154 cases of malignant melanoma of the head and neck has been studied retrospectively, representing a subgroup of 972 cases of all sites seen over a 15-year period. There was no significant difference in the mean level of invasion as defined by Clark between head and neck melanomas and lesions of other sites. The primary lesion was most commonly situated on the face and one third of the tumours arose in Hutchison's melanotic freckles. The 5-year survival rate was 59% and the rate of local recurrence 8%. The mean histologically defined closest margin of dissection was 0.7 cm and only three patients underwent prophylactic lymph node resection. The margin of excision did not influence mortality, but if thick lesions were not excised widely then there was an increase in local recurrence. Our results suggest that a more conservative surgical approach may be feasible in selected patients with melanoma of the head and neck.
Prevention, management, and control of influenza: a mandate for the 1980s.
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Morbidity during hospitalization: can we predict it?
Physicians use the concept of stability to estimate the likelihood that a patient will deteriorate during a hospitalization. To determine whether physicians can accurately predict a patient's risk of morbidity, 603 patients admitted to the medical service during a one month period were rated prospectively as to how stable they were. Overall, 15% of patients had deterioration of already compromised systems, while 17% had new complications, such as sepsis. Eight percent of patients had both. Twelve percent of stable patients experienced morbidity; 39% of the somewhat unstable and 61% of the most unstable. When all of the demographic and clinical variables were taken into account including the reason for admission and comorbid diseases, the residents' estimates of the patient's stability was the most significant predictor of morbidity (p less than 0.001). The judgment that a patient was stable had an 87% negative predictive accuracy, while the judgment unstable had a 46% positive predictive accuracy.
Immunization of elderly people with two doses of influenza vaccine.
A total of 104 elderly patients were immunized with one or two doses of the commercial 1985-1986 inactivated influenza vaccine formulation. Two types of vaccines (split virus [SV] vaccine and whole virus [WV] vaccine) and one or two doses 1 month apart were given. No difference in local or systemic reactions was noted among the four groups. The reciprocal geometric mean hemagglutination inhibition antibody titers against influenza A/Philippines/82 (H3N2) after one or two doses were: 78 for SV vaccine (one dose), 65 for SV vaccine (two doses), 55 for WV vaccine (one dose), and 51 for WV vaccine (two doses). Similar nonsignificant differences were observed for the other two antigens contained in the vaccine. The percentage with a hemagglutination inhibition titer of greater than or equal to 1:40 also did not differ after one or two doses. We then compared the postvaccination hemagglutination inhibition titers in young and old patients from previous studies in which apparent differences had appeared. We retested all sera simultaneously on the same day with the same reagents. No significant differences were apparent among age groups. In summary, the humoral immune response to inactivated influenza vaccine in healthy ambulatory elderly patients who have been previously immunized may not differ significantly from that of children and young adults. A booster dose 1 month after the first dose does not enhance immune responses in the elderly.
The use of eye-nose goggles to control nosocomial respiratory syncytial virus infection.
We evaluated an eye-nose goggle to determine its usefulness in reducing nosocomial RSV infection in patients and staff members on our infant ward. During a community outbreak of RSV in 1984, infection was assessed by biweekly routine viral cultures on all ward personnel and patients and also by seroconversion in personnel. For three weeks staff members wore the goggles; two (5%) adults and one (6%) child acquired nosocomial infection. During the subsequent three-week study period, goggles were not used and 34% of personnel and 43% of susceptible infants became infected. The use of the disposable eye-nose goggles was associated with a significant decrease in nosocomial RSV infections (P less than .003 for staff and P less than .05 for contact infants).
Resuscitation: how do we decide? A prospective study of physicians' preferences and the clinical course of hospitalized patients.
Physicians have to address the question of the measures to be employed in the event that a patient's condition deteriorates after admission to the hospital. To identify the information that physicians use in making such decisions, all 604 patients admitted to the medical service during a one-month period were studied. The patient's age and residents' estimates of the patient's long-term prognosis and ability to function were the three primary factors that correlated with intervention preferences. When illness severity, the reason for admission, comorbidity, and poor function were taken into account, mortality and morbidity rates did not differ between patients for whom full vs not-full intervention was favored. Apart from differential rates of admission to critical care units, there were no important differences in the care, course, or mortality of patients for whom less than full intervention was initially favored. Suggestions that physicians should discuss resuscitation with all or most patients who may die are unrealistic. A more prudent strategy is to discuss the issue with patients whose hospital course is marked by a steady deterioration.
The common cold--relief at last?
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Closing the clinics: would it close the teaching hospital?
To improve their overall financial position, many teaching hospitals have considered decreasing the size of their clinics. To assess the effect this would have on the inpatient service, the medical ward service of The New York Hospital was studied during the 1981 to 1982 academic year. In 50 percent of hospitalizations, patients were enrolled in the clinic system before admission. In an additional 19 percent of hospitalizations, patients had either been previously seen in the emergency room or hospitalized at this institution, but never seen in a clinic. In the remaining 31 percent of hospitalizations, the patient's admission was the first contact with the institution. This group of "new" patients simply replaced the patients who died (14 percent) or were lost to the system through transfer to chronic-care facilities (11 percent) or referral to community physicians (7 percent). Twenty percent of patients discharged to a clinic were readmitted during the study year as opposed to only 3 percent of patients who were transferred to chronic-care facilities or referred to community physicians. The clinic system is the principal source of referral into the ward service and the most effective mechanism for insuring that a patient needing rehospitalization returns to the hospital. It is concluded that major reduction of clinic size will result in severe contraction of the inpatient service.
Assessing illness severity: does clinical judgment work?
Accurate classification of clinical severity is important for interpreting casemix in clinical studies and for stratifying patients for clinical trials. To evaluate whether clinical judgment might be an effective method of estimating severity, all 604 patients admitted to the medical service in a one month period were rated at the time of admission by the responsible resident as to how sick they were. Within the 13 comorbid disease groups, and within the 15 basic categories of reason for admission, the physicians' severity ratings were the most significant predictor of in-hospital mortality. Death rates rose from 0% in those rated as not ill, to 2% in the mildly ill, to 6% in the moderately ill, to 23% in the severely ill, and to 58% in those rated as moribund (p less than 0.001). Sickness ratings also predicted time to death: mildly ill patients died after prolonged hospitalizations, while the moribund died shortly after admission. The patients' age, sex, race, the number of comorbid diseases or problems did not predict mortality. Patients with serious comorbidity (metastases, AIDS, or cirrhosis) had a higher mortality rate than other patients (p less than 0.001); however, the severity ratings predicted outcomes within this group (p less than 0.001) as well as among those without such serious comorbidity (p less than 0.001). Patients who were admitted with acute neurologic (p less than 0.05) or acute cardiovascular (p less than 0.01) events did have an independently worse prognosis. In conclusion, physicians' estimates or sickness provided an accurate estimate of illness severity, with mortality rates that essentially tripled from one stratum to the next. Clinical judgment may suffice to classify the clinical severity of patients at the time of enrollment in prospective trials and can provide a useful method of controlling for casemix.
A simple method for correcting rectal prolapse in pigs.
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